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The Not –So- Sweet Truth about What You’re Drinking

Friday, December 4th, 2015
soda

fig 1

By Liz Aziz, PharmD Student Cedarville University School of Pharmacy

Many Americans have grasped the warning on excessive sugar intake. The problem is, these sugary calories often creep into the average American’s diet through drink, not food. Sugary drinks have already been tied to an increased risk of Type 2 diabetes as well as weight gain.­1 But just this month, a study published by the British Medical Journal has now found that sweetened beverages can also be associated with increase heart failure.2  Life with heart failure is nothing to take lightly, that’s why this gives the nation all the more reason to twist the cap shut on sweetened beverages and to choose healthier habits.

Increased prevalence of heart failure and other heart complications.chf As mentioned above, the recent study found a correlation between frequent consumption of sugary drinks and heart failure.2 These drinks include any beverage sweetened by sugar including soda, fruit juice/punch, lemonade, powdered drinks, or energy drinks.2 The study was a 12-year long population based study on 42,000 men ages 45-79. Researchers tracked incidents of heart failure between 1998 through 2010. Using food-frequency questionnaires, they found that men who drink two or more drinks a day were 23% more likely to develop heart failure. 2 Men who did not consume such beverages did not experience as many incidents of heart failure.2 Though the study has its limitations, such as survey bias and outside variables affecting study subjects, there are other literature that support the declining heart health of sugary-drink consumers.

In a similar study published by Circulation, researchers discovered a 20% increase in coronary heart disease in those who drink sweetened beverages.3  This study took into account age and family history when considering the correlation.3 They also concluded that the association had to do with sugar-sweetened drinks, not artificially-sweetened drinks (no-calorie sugary drinks).3  The study found sugar to be the underlying problem. Women are not excluded from this risk. The Nurses’ Health Study tracked the health of over 90,000 women during a time period of twenty years.4 They found similar results as the studies done on men, however the results were even more severe. Women who drank more than two servings of sugary drinks each day had a 40 % higher risk of heart attacks or death from heart disease in comparison to women who were rare consumers.4

So what is heart failure and heart disease? Heart failure is essentially when the heart is too exhausted or damaged to pump blood and oxygen to the rest of the body.5 Those that suffer from heart failure live a very difficult and limited life.5 Daily tasks become a struggle due to shortness of breath.5 This can further result in a sedentary lifestyle which is associated with its own health problems.5 Illnesses that can lead to heart failure are coronary heart disease as well as diabetes.5 The issue with excess sugar is that the build-up of the glucose metabolite in the body and frequent insulin spikes can cause significant damage and stress to the heart, leading to heart failure and heart disease.5 According to the Center of Disease Control, there are already 5 million Americans suffering from heart failure and more and more each year are adopting habits that put them at risk. soda

Sugary drinks overload your diet with sugar. A statement made by the American Heart Association recommended that the average adult should not consume more than 5 to 9 teaspoons of sugar. 7 However, the average 20-ounce bottle of a sugary drink contains 16 teaspoons of sugar.8 That almost TRIPLES the amount of sugar a person should consume in one day. With individuals having two or more of these drinks a day, it’s no wonder it is having a detrimental impact on Americans’ health.

What is the take home message? Those that regularly consume sugary drinks should set goals and limit their consumption.9 Though this is not the answer to all heart-related problems; it is definitely a start. There is plenty of research that supports this recommendation not only when it comes to heart failure but also diabetes and obesity. However, the question remains: Is this enough to get Americans to put down that can?

 

References

  1. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84:274–288.
  2. Rahman I, Wolk A, Larsson SC. The relationship between sweetened beverage consumption and risk of heart failure in men. Heart. 2015;
  3. De koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012;125(14):1735-41, S1.
  4. Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89:1037-42.
  5. nih.gov. What Is Heart Failure? – NHLBI, NIH. 2015. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/hf. Accessed November 11, 2015.
  6. en S, Kundu B, Wu H et al. Glucose Regulation of Load-Induced mTOR Signaling and ER Stress in Mammalian Heart. Journal of the American Heart Association. 2013;2(3):e004796-e004796. doi:10.1161/jaha.113.004796.
  7. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association.Circulation. 2009;120(11):1011-1020.
  8. Wang YC, Coxson P, Shen YM, Goldman L, Bibbins-Domingo K. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes.Health Aff (Millwood). 2012;31(1):199-207.
  9. Sandee LaMotte C. Study links sweetened soda and heart failure – CNN.com. CNN. 2015. Available at: http://www.cnn.com/2015/11/03/health/soda-heart-failure-study/. Accessed November 11, 2015.
  10. Sugary Drinks.; 2014. Available at: http://www.rethinksugarydrink.org.au/go-free. Accessed November 11, 2015.
  11. CHF.; 2015. Available at: http://pharmacologycorner.com/drug-therapy-heart-failure-ppt/. Accessed November 11, 2015.
  12. Creative Commons. Vending Machine.; 2015. Available at: http://www.wikihow.com/Buy-Something-from-a-Vending-Machine-That-Demands-Exact-Change-when-All-You-Have-Is-Bills#/Image:Vending-Step-2.jpg. Accessed November 11, 2015.

 

A Natural Approach to Preventing Gestational Diabetes

Monday, October 26th, 2015
image courtesy of freedigitalphotos.net

By Katie Woodward, PharmD Student

You are having a new baby! Congratulations! You’ve probably already had several opportunities to answer that age-old question, “What gender are you hoping for?” And it is likely you responded with something like, “I don’t care as long as my baby is healthy!” Thanks to new scientific research, your chances of delivering a healthy baby are constantly improving.

We are going to play a quick game of “Bad News/Good News.” The bad news: gestational diabetes may cause complications in your pregnancy. Several factors may put you at risk of developing gestational diabetes. If diabetes runs in your family, if you are overweight, not very active, or over the age of 40 you are at risk of developing gestational diabetes.1 Gestational diabetes can cause jaundice, high birth weight, trauma during birth, increase necessity for C-section, and increase likelihood of obesity or diabetes in the child.1,2 Gestational diabetes also puts a new mother at risk of developing Type 2 Diabetes, which can require insulin injections and other treatments to control.

Now, for the good news: new research has demonstrated that myo-inositol is a supplement you can take which significantly decreases your chances of developing gestational diabetes, even if you are at high-risk.3 For those already diagnosed with gestational diabetes, taking a myo-inositol supplement can help decrease your need for insulin, make you more likely to carry the baby to term, and decrease your infant’s chances of developing hypoglycemia.3 Standard treatment for gestational diabetes requires the patient to check blood sugar levels in the morning and after meals, which can require several needle sticks per day as well as the purchase of a glucometer, test strips, and lancets.4 Insulin injections are also used to help control the blood sugar in up to 20% of women with gestational diabetes.4

A research study published in the Journal of Maternal-Fetal and Neonatal Medicine was designed as a prospective, double-blind, randomized controlled clinical trial which compared a placebo group to a group of mothers who supplemented with myo-inositol twice daily.3 The myo-inositol group had significantly better outcomes including lower maternal BMI, longer gestation at the time of delivery, and decreased abnormal oral glucose tolerance test results. The oral glucose tolerance test is the standard screening measure for gestational diabetes.  One limitation was that the study was relatively small. Some of the data may have been statistically significant if there had been more women involved in the study; for instance, the myo-inositol group had a lower incidence of neonatal hypoglycemia, but the data was not quite strong enough to be statistically significant. Another interesting statistic is that 21% of women in the placebo group required insulin therapy, while only 3% of women in the myo-inositol group required insulin therapy. While larger studies may be needed to validate this data, this study demonstrated that at least 50% of women who take myo-inositol may benefit from the treatment.3 Since the current standard of care for prevention of gestation diabetes is diet change and monitoring blood sugar, myo-inositol may be an easy and beneficial way to minimize complications from gestational diabetes.  It also has a promising potential to minimize the requirement of insulin injections.

Since it is a compound naturally found in both your body and your baby’s body, you can safely consume myo-inositol supplements.5 The product may be a little bit difficult to find in grocery stores, but it can be found in combination products or ordered online. According to research, the supplement is best if taken 2000 mg twice daily (make sure you separate the doses by at least six hours.)One product can be purchased from Fairhaven Health6 where you can get a 60-day supply for less than $20.* Myo-inositol is often combined with another compound called D-chiro inositol, which has also been demonstrated to assist with gestational diabetes.7 The combination product is called Ovasitol and it can be purchased online from Theralogix Nutritional Science Company, but it must be ordered online and can cost up to $1 per day ($90 for a 90 day supply.)8 Another product to consider is called Sensitol, and it contains D-chrio inositol, myo-inositol, and alpha lipoic acid. The product can be ordered online and a thirty day supply is $52.9

Gestational diabetes can have some scary consequences for you and your baby. Based on the evidence, I would recommend that any mother who has increased risk of gestational diabetes should discuss supplementation with myo-inositol with their medical provider.   It could help prevent or minimize problems associated with gestational diabetes. Myo-inositol may be expensive and may not be easily accessible to all; since it is commonly used as a preventative supplement, do you think that pregnant women at high risk for developing gestational diabetes should consider it as an option?

*The manufacturer suggests that the drug be taken four times daily, but in studies, the 2000 mg dose was only recommended twice daily.3 Also, this will help decrease the cost of the drug.

**Note: The Cochrane Collaboration is working on a new study to further describe the dosing and efficacy of myo-inositol as a treatment/ prevention method for gestational diabetes and it should be released soon.

References

  1. Available at: http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014. Accessed October 14, 2015.
  2. Brown J. Myo-inositol for preventing gestational diabetes. Cochrane Database Of Systematic Reviews [serial online]. February 2, 2015;(2)Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed October 11, 2015.
  3. Matarrelli B, Vitacolonna E, Celentano C, et al. Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: a randomized controlled trial. The Journal Of Maternal-Fetal & Neonatal Medicine: The Official Journal Of The European Association Of Perinatal Medicine, The Federation Of Asia And Oceania Perinatal Societies, The International Society Of Perinatal Obstetricians [serial online]. July 2013;26(10):967-972. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 11, 2015
  4. Available at: http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/treatment/con-20014854. Accessed October 21, 2015.
  5. D’Anna R, Scilipoti A, Di Benedetto A, et al. myo-Inositol supplementation and onset of gestational diabetes mellitus in pregnant women with a family history of type 2 diabetes: a prospective, randomized, placebo-controlled study. Diabetes Care [serial online]. April 2013;36(4):854-857. Available from: MEDLINE, Ipswich, MA. Accessed October 11, 2015.
  6. Available at: http://www.fairhavenhealth.com/myo-inositol.html?cmp=bing&kw=myo-inositol&utm_source=BingShopping&utm_medium=CSE&utm_campaign=myo-inositol. Accessed October 14, 2015.
  7. Costantino D, Guaraldi C. [Role of D-chiro-inositol in glucidic metabolism alterations during pregnancy]. Minerva Ginecol. 2014;66(3):281-91.
  8. Available at: http://www.theralogix.com/index.cfm?fa=products.ovasitol.default&dvsn=reprohealth. Accessed October 14, 2015.
  9. Available at: http://catalog.designsforhealth.com/Sensitol?quantity=1. Accessed October 21, 2015.

Skipping Breakfast: Do the Benefits “Outweigh” the Risks?

Friday, October 16th, 2015

By Vineeta Rao, PharmD Student Cedarville University

You have heard the concept all over the news and social media: Skipping breakfast leads to weight gain. Nutritionists and researchers have long speculated that when one skips breakfast, his hunger and lack of energy will cause a rebound-effect in which he will consume more calories by snacking than he would have if he had eaten breakfast.2 But a recent study published by the American Journal of Clinical Nutrition has found that when men and women skip breakfast, they actually consume far fewer calories compared to the days when they do eat breakfast.1

Breakfastpic

In this traditional crossover study, participants were allowed to eat as they pleased and report their own eating habits to the study investigators. Investigators consulted the same patients on various occasions to obtain a report of how many meals they had eaten, what they had eaten for each meal, and what time of day they had eaten. Then, investigators examined each person’s data individually; they compared the participant’s calorie intake on the days when he or she ate breakfast to a day when he or she did not eat breakfast. Researchers also included any snacking between meals in the total calorie count. On average, men in the study consumed 247 kcal more on a breakfast day than a non-breakfast day, and women consumed 187 kcal more on a breakfast day than on a non-breakfast day.1 Apparently, snacking was not enough to make up the calories lost from skipping breakfast! If participants regularly ate a few hundred fewer calories a day, then over time, breakfast skipping actually led to weight loss rather than weight gain.

Overall, the participant’s choices in food were similar between breakfast days and non-breakfast days, with breakfast days containing more whole grains, fruits, and dairy.1 One limitation of this study is that participants reported their own diet choices.1 Thus, if a patient forgot to report a snack item, the calorie deficit calculated above would not be correct. Additionally, participants tend to change their food choices when they know that they are being monitored.

Researchers all over the world cannot seem to agree on this matter. Skipping breakfast goes against the current standard of care, but it shows compelling evidence that it may actually assist in weight loss. Although many researchers have suspected that skipping breakfast will cause people to snack more frequently and to choose unhealthy snacks that lead to weight gain, very few research studies have shown this to be true. For example, one study that expected this to be true examined the effects of skipping breakfast in children in Taiwan and did not find any connections between skipping breakfast and obesity.2

So, does this mean that we should encourage breakfast skipping as a weight-loss strategy? An editorial response to this research study says yes! Because obesity and weight gain is associated with risks for chronic diseases such as heart disease, high blood pressure, diabetes, and stroke, getting rid of this small but significant calorie intake could help to prevent such diseases.3

However, other researchers are not convinced. The study in Taiwanese children found that breakfast-skipping may not be suitable for all people. For example, this study found that children who ate breakfast regularly had better cognitive ability and academic performance than children who did not eat breakfast regularly.2

Additionally, some research studies have shown that skipping breakfast can actually increase the risk of developing Type II diabetes by decreasing insulin tolerance and raising blood sugar. When three universities in China examined the risk factors that lead to Type II diabetic patients’ condition, they found skipping breakfast was associated with an increased risk for the disease.4

So what can we learn from all these findings? In short, skipping breakfast does not appear to lead to weight gain, but the current research on other health risks and benefits of skipping breakfast is controversial. You most likely won’t have to worry about gaining weight from missing breakfast now and then due to a busy schedule, but the research is too gray to conclude that skipping breakfast is safe and healthy for everyone. One fact that remains true across all these studies is that the quality of the food you eat matters. Whether you eat breakfast or not, it is important to eat a balanced diet with whole foods, good sources of protein, and a focus on non-starchy vegetables. Nutrient-rich diets are important in healthy weight management and prevention of disease states.5

What do you think? Does the benefit of weight loss “outweigh” the possibility of potentially contributing to the development of chronic diseases?

References:

  1. Kant AK, Graubard BI. Within-person comparison of eating behaviors, time of eating, and dietary intake on days with and without breakfast: NHANES 2005-2010. Am J Clin Nutr. 2015;102(3):661-70.
  2. Ho C, Huang Y, Lo YC, Wahlqvist ML, Lee M. Breakfast is associated with the metabolic syndrome and school performance among taiwanese children. Res Dev Disabil. 2015;43–44:179-188.
  3. Levitsky DA. Breaking the feast. Am J Clin Nutr. 2015;102(3):531-2.
  4. Bi H, Gan Y, Yang C, Chen Y, Tong X, Lu Z. Breakfast skipping and the risk of type 2 diabetes: a meta-analysis of observational studies. Public Health Nutr. 2015:1-7.
  5. United States Department of Agriculture. Scientific Report of Dietary Guidelines 2015 Advisory Committee. <http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf>

Eat more, lose more?

Tuesday, November 18th, 2014

By Stephanie Cailor, PharmD Student

You have probably heard the common dietary recommendation that you should eat more fruits and vegetables as a part of a healthy diet. WebMD provides some simple diet tips including one that correlates specifically with this theme. They explain that by “eating more fruits and vegetables, you shouldn’t feel as hungry because these nutrient-rich foods are also high in fiber and water, which can give you a feeling of fullness,” a claim that is supported by much research.1, 2 So how exactly does fiber play a role? Fiber is a component of food that is difficult for the body to digest. Two types of fiber exist: soluble fiber, such as that found in citrus fruits, strawberries, celery, and green beans, and insoluble fiber, found in foods such as broccoli, cabbage, and grapes. Soluble fiber retains water and slows digestion in the stomach and intestines; whereas, insoluble fiber works by adding bulk to the stool in order to speed up the passage of food through the stomach and intestines.3 For this reason,  among others, the World Health Organization recommends that adults eat a minimum of 400 grams of fruit and vegetables per day to prevent health conditions such as obesity.4 To bring this number into perspective, roughly half of each plate should be filled with fruits and vegetables. Further examples and information regarding serving sizes can be viewed at www.choosemyplate.gov/food-groups/.5 While the task of eating more fruits and vegetables may seem simple, is this general recommendation to help lose weight failing to tell us the whole story?

The claim that adding fruits and vegetables to the diet can help with weight management may be correct, but only increasing fruit and vegetable consumption may not lead to weight loss. A recently published meta-analysis reviewed the results of 7 research studies on this subject.6 Each of these studies looked at the impact of increased dietary intake of fruits and vegetables on weight loss; however, none saw a significant effect. One study involving 90 adults utilized an 8 week intervention that added either 0 grams, 300 grams, or 600 grams of fruits and vegetables to daily diet. The study concluded that groups increasing their fruit and vegetable intake lost some additional weight, but the amount was not statistically significant.7 Another study looked at adult women who increased the intake of their fruits and vegetables to 9 servings a day. The body weight of these patients changed very little, with no statistically significant reduction in weight loss over the course of the study.8 There are a few reasons why the included research studies may show the shared conclusion of no significant weight loss due to eating more fruits and vegetables. Some of the studies may not have looked long enough to see the effects of eating more fruits and vegetables on body weight. Others may have not had a large enough increase in fruits and vegetables in the diet to show any weight loss effects. Accordingly, more research needs to be done on this topic before a definitive statement can be made.

Overall, this meta-analysis concludes by stating that while eating more fruits and vegetables does promote a healthy lifestyle, in order to lose weight, other efforts are necessary to achieve desired outcomes.6 For example, adding fruits and vegetables without cutting out other unhealthy foods, primarily those with high calorie counts, will not provide desired weight loss effects.9 Other supporting research emphasizes that significant weight loss results can be seen by reducing caloric intake and balancing the diet with fruits and vegetables.4, 10

As a future pharmacist, I believe that eating more fruits and vegetables as a part of a healthy diet is beneficial due to their overall low caloric content and the fiber they contain. To lose weight, though, it is important to reduce the amount of unhealthy foods in the diet. Being healthy is a lifelong pursuit that does not consist of simply changing one bad habit. Alongside a healthier diet, it is also important to be physically active. For physical activity to provide health benefits, adults should spend 150 minutes per week doing moderate intensity aerobic activity (such as walking) and at minimum 2 days per week completing muscle strengthening activities, which includes strength training or endurance exercises.11 Small steps towards a healthy lifestyle for some people could mean adding one new vegetable to their plate tomorrow or not buying chips at their next trip to the grocery store. Others may choose to take a walk around their neighborhood every day for the next week. What are some unhealthy lifestyle and diet habits that you could change today to help you get on track for weight loss?

References

  1. Smith, M. W. (2014). 15 Best diet tips ever. Available from: http://www.webmd.com/diet/ss/slideshow-best-diet-tips-ever. Accessed on October 17, 2014.
  2. Tohill, B. C. (2005). Dietary intake of fruits and vegetables and management of body weight. World Health Organization.
  3. Dugdale, D. (2012, September 2). Soluble and insoluble fiber: MedlinePlus Medical Encyclopedia Image. Retrieved November 1, 2014.
  4. Amine, E., Baba, N., Belhadj, M., Deurenbery-Yap, M., Djazayery, A., Forrester, T & Yoshiike, N. (2002). Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. World Health Organization.
  5. Dietary guidelines for Americans, 2010. (2010). Washington, D.C.: U.S. Dept. of Health and Human Services, U.S. Dept. of Agriculture.
  6. Kaiser, K. A., Brown, A. W., Brown, M. M. B., Shikany, J. M., Mattes, R. D., & Allison, D. B. (2014). Increased fruit and vegetable intake has no discernible effect on weight loss: a systematic review and meta-analysis. The American journal of clinical nutrition, 100(2), 567-576.
  7. Whybrow S, Harrison CL, Mayer C, James SR. Effects of added fruits and vegetables on dietary intakes and body weight in Scottish adults. Br J Nutr 2006;95:496–
  8. Maskarinec G, Chan CL, Meng L, Franke AA, Cooney RV. Exploring the feasibility and effects of a high-fruit and -vegetable diet in healthy women. Cancer Epidemiol Biomarkers Prev 1999;8:919–
  9. Sacks, F. M., Bray, G. A., Carey, V. J., Smith, S. R., Ryan, D. H., Anton, S. D., … & Williamson, D. A. (2009). Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. New England Journal of Medicine, 360(9), 859-873.
  10. Wing, R. R., Hill, J. O. (2001). Successful weight loss maintenance. Annal Review of Nutrition, 21(1):323-341.
  11. Physical Activity Guidelines Advisory Committee. (2008). Physical activity guidelines advisory committee report, 2008. Washington, DC: US Department of Health and Human Services, 2008, A1-H14.

Revealing the “Dark” Side of Chocolate

Friday, November 14th, 2014

By: Ruth Choi, PharmD Student

 

For centuries, cocoa has been consumed for its pleasurable taste as well as for its health benefits. Today, research attempts to explain how cocoa may be beneficial to our overall health, specifically cardiovascular health. Chocolate- Guilty Pleasure or Healthy Supplement is a review paper that was recently published in The Journal of Clinical Hypertension. In the paper, Latham et al discuss major studies done with cocoa to determine how cocoa acts in the body to produce cardiovascular benefits and whether it can be consumed as a dietary supplement.

The unique diet and health of the Kuna Indians initially sparked research on dark chocolate consumption and cardiovascular health. From the San Blas Islands of Panama, Kuna Indians consume about four 8-ounce cups of unprocessed cocoa drinks per day and have exceptionally low rates of hypertension and cardiovascular disease (CVD) even to old age.1 For instance, the mean blood pressure (BP) was 110/70 mm Hg in the elderly over 65 years.1 Cocoa comes from the Theobroma cacao tree, and a major component of it is flavanol. One of the proposed mechanisms is flavanols are responsible for improving blood flow by stimulating the endothelium of blood vessels to produce more nitric oxide (NO) and increase vasodilation.1 Improving blood flow subsequently reduces CVD risk factors such as hypertension, platelet dysfunction, insulin resistance, and hypercholesterolemia.1. Heiss et al researched the effects of cocoa intake in smokers and found that drinking cocoa high in flavanols (176-185 mg) increased NO levels and reversed endothelial dysfunction.2 One way the body naturally produces NO is through insulin stimulation. Insulin resistance occurs in individuals who do not respond to insulin’s action on blood vessels to produce NO. In a study done by Grassi et al, flavanol-rich dark chocolate proved to decrease BP and insulin resistance and improved blood flow in hypertensive patients.3

Cholesterol also plays a significant role in cardiovascular health. Dark chocolate is thought to increase HDL-C levels, which is the good cholesterol. In a 3-week study done on healthy subjects, Mursu et al found that consuming either 75 g of dark chocolate or flavanol-rich dark chocolate daily increased HDL-C levels by 11.4% and 13.7%, respectively.4 On the contrary, some studies will argue that it is actually theobromines in cocoa that help increase HDL-C levels.1 Further research is needed to determine whether flavanols or theobromines increase HDL-C levels.

Many recent studies show the benefits of cocoa intake on cardiovascular health. Due to its delectable taste, relative safety, and low cost, cocoa-rich dark chocolate is being considered as a health supplement. Major hindrances to its use, however, are the caloric intake and limitations of many of the studies.1 Due to its high caloric, saturated fat, and sugar content, chocolate needs to be consumed with caution, especially in obese patients. Though less palatable, people could consume cocoa-based products with less sugar or saturated fat. Latham et al explain the limitations that are apparent in all of the studies that were reviewed.1 One of the major limitations is the variability in flavanol content in all the studies making it difficult to interpret and compare the results. It also hinders making effective dosage recommendations for patients. Another limitation is the small sample sizes in all the studies making it difficult to generalize the results to a larger, more diverse population. The short duration of the studies is another limitation because it is unknown whether cocoa intake would produce these same results if given long term. Therefore, further research is needed until we can recommend dark chocolate as a health supplement. Nonetheless, one thing you can take away from the research is that you don’t have to feel guilty anymore about eating ‘healthy’ dark chocolate in moderation as part of your dietary lifestyle changes to prevent and treat CVD risk factors.

The Dietary Approaches to Stop Hypertension (DASH) diet recommended by the National Heart, Lung, and Blood institute (NHLBI) consists of eating a diet rich in fruits, vegetables, and low-fat dairy products to improve BP.5 Many supplements also exist that have been significantly proven to have antihypertensive effects. What sounds better, chocolate or veggies?

References:

 

  1. Latham L, Hensen Z, Minor D. Chocolate—Guilty pleasure or healthy supplement? JCH. 2014;16(2): 101. http://onlinelibrary.wiley.com/doi/10.1111/jch.12223/full. Published February 2014. Accessed October 29, 2014.

 

  1. Heiss C, Dejam A, Kleinbongard P, Schewe T, Sies H, Kelm M. Vascular effects of cocoa rich in flavan-3-ols. JAMA. 2003;290(8): 1030. http://jama.jamanetwork.com/article.aspx ?arti cleid=197170. Published August 27, 2003. Accessed October 29, 2014.

 

  1. Grassi D, Necozione S, Lippi C, et al. Cocoa reduces blood pressure and insulin resistance and improves endothelium-dependent vasodilation in hypertensives. HYP. 2005:46(2): 398. http://hyper.ah ajournals.org/content/46/2/398.full.pdf+html. Published July 18, 2005. Accessed October 29, 2014.

 

  1. Mursu J, Voutilainen S, Nurmi T, et al. Dark chocolate consumption increases HDL cholesterol concentration and chocolate fatty acids may inhibit lipid peroxidation in healthy humans. FRBM. 2004:37(9): 1351. http://www.sciencedirect.com/science/ article/pii/S0891584904004551. Published November 1, 2004. Accessed October 29, 2014.
  2. What Is the DASH Eating Plan? National Heart, Lung, and Blood Institute. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/dash/

 

 

Are you “Pro” Probiotic Supplements?

Thursday, December 5th, 2013

by Heather Evankow, PharmD student

In recent years, the popularity of probiotic supplements has risen. Probiotics are bacteria that help maintain the natural balance of organisms (microflora) in the intestine.1 The idea of probiotics is not a new concept. The idea was first developed around 1900 by the Nobel Prize-winning recipient Elie Metchnikoff. Metchnikoff theorized that the fermented milk products Bulgarian citizens ingested were a major factor in their longer life spans when compared with other countries.2 It was not until the year 1989 when R. Fuller popularized the term “probiotics”.3 Today, probiotics can be seen in the news claiming to improve the immune system, aid in skin health, defend against depression, clear up a bloated gut, prevent urinary tract infections, and even delay allergies.4

The Daily Herald recently released the article, Probiotics are all the rage, and experts say there are results behind the hype. The author, Gabriella Boston, Boston combines the opinions of several healthcare professionals to emphasize the health benefits behind the evolving topic of probiotics.

The first healthcare provider, Megan McCusker, is a dermatologist who believes probiotics are an important treatment therapy for treatment of anything from acne to psoriasis.4 While the Federal Drug Administration (FDA) does not approve any health claims for this supplement, McCusker could recommend 5-20 billion units per day depending on the patient’s needs. There were no clinical research references to show how McCusker developed these recommendations.

A nutritionist Boston featured, Jared Rice, also believes in the benefits of probiotics. Rice has not observed any downsides with his patients taking probiotics, but still advises patients to seek medical attention before taking high doses. Rice believes it is essential to buy the healthiest probiotic supplement. Also, he believes it is important to create a probiotic-friendly body by eating whole grains, bananas, and onions while steering clear of nondigestible carbohydrates.4 Unfortunately, there was no data referenced to confirm the benefits of Rice’s claims.

Ebeth Johnson, a nutritionist and chef, also gave her expert advice for this article. She believes this probiotic trend is here to stay. She encourages incorporating probiotics into your diet by consuming unpasteurized miso, live cultured pickles, tempeh, unsweetened kefir and yogurt, and kombucha teas.5 It is unclear how Johnson came up with these supplement sources. In addition, she also did not mention any specific research to validate the quality of these sources.

While the experts in Boston’s article seem confident in their recommendations of probiotics supplements, the clinical research is still limited for probiotics. The varieties of strains make it problematic in understanding the health benefits.

One of the most researched probiotic strains is Lactobacillus rhamnosus GG (LGG). LGG has been proven to help pediatric patients with pain-related gastrointestinal (GI) disorders in many clinical studies.5 In a 2011 meta-analysis, researchers systematically searched for randomized controlled trials assessing LGG supplementations in children with functional dyspepsia (FD), irritable bowel syndrome (IBS), abdominal migraine and functional abdominal pain (FAP).5 The major limitations for this analysis included incomplete outcome data and the number of trials with a small sample size. The results revealed a decrease in severity in pain with the overall study population and the IBS subgroup.5 The frequency was also decreased in the IBS subgroup.

Another hopeful probiotic strain is Streptococcus thermophilus VSL #3. A multicenter, randomized, placebo-controlled, double-blind, crossover study has shown VSL #3 to be successful and safe in helping the lives of children with IBS.6  59 patients from ages 4-18 years of age completed the study with no untoward adverse effects reported. Researchers found no significant difference was found in the stool pattern of patients, but abdominal pain, abdominal bloating, and family life disruption were all significantly more effective to the placebo.6

Have you had any encounters with probiotic supplements? Comment and share your experiences. Please include the main therapy goal, specific probiotic strains, and the dosage.

If you have had no experience with probiotics, based on the information above, would you personally try probiotic supplements? Share your rational.

References

1. “Probiotics – Topic Overview.” WebMD. Healthwise, 04 FEB 2011. Web. 29 Nov 2013. <http://www.webmd.com/digestive-disorders/tc/probiotics-topic-overview>.

2. Parvez, S. and Kang S. “Probiotics and their fermented food products are beneficial for health.” Volume 6. Web. 29 Nov. 2013. <http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.2006.02963.x/pdf>.

3. Ouwehand, A., S. Salminen, and E. Isolauri. “Probiotics: an overview of beneficial effects.” Vol 82.Issue 1-4 (2002): 279-289. Web. 29 Nov. 2013. <http://link.springer.com/article/10.1023

4. Boston, Gabriella. “Probiotics are all the rage, and experts say there are results behind the hype.” Daily Herald. N.p., 28 Oct 2013. Web. 29 Nov 2013. <http://www.dailyherald.com/article/20131028/entlife/710289977/>.

5. Horvath, A., P. Dziechciarz, and H. Szajewska. “Meta-analysis: Lactobacillus rhamnosus GG for abdominal pain-related functional gastrointestinal disorders in childhood.” Alimentary Pharmacology & Therapeutics. Vol 6.Issue 12 (2011): 1302-1310. Web. 29 Nov. 2013. <http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2011.04665.x/full>.

6. Guandalini S., G. Magazzu, and A. Chiaro. “VSL#3 improves symptoms in children with irritable bowel syndrome: a multicenter, randomized, placebo-controlled, double-blind, crossover study.” J Pediatrics Gastroenterol Nutr. 2010 Jul;51(1):24-30. Web. 04 Dec. 2013. http://www.ncbi.nlm.nih.gov/pubmed/20453678.

Saturated Fat Not Harmful?

Friday, November 22nd, 2013

By Megan Buck, PharmD Student Cedarville University

In 1970, Ancel Keys’ “seven countries study” correlated the incidence of coronary heart disease and total cholesterol concentrations then observed a correlation between heart disease and saturated fat.1  Due to this study, saturated fat has been held responsible for cardiovascular risks.  Since then, scientists have reviewed several studies and examined the differences between types of fats and cholesterols.  New scientific evidence suggests that the last forty years of convincing people to remove saturated fat from their diets actually increased their cardiovascular risks.2

Aseem Malhotra of Croydon University Hospital in London recently published an article explaining this discovery.  “Saturated Fat Is Not the Major Issue” describes the importance of saturated fat in the diet.  Consuming saturated fat is not harmful, but we should be concerned with overmedicating with statin drugs.2 3  A diet consisting of a maximum of 10% of total nutrients coming from saturated fat has not be proven efficient at reducing cholesterol or reducing cardiovascular risks.  Saturated fat produced large and light-weight (Type A) LDL particles rather than the small and heavy (Type B) particles, the later are likely responsible for cardiovascular disease.2  Also, Malhotra states that studies found processed meats contribute more to coronary heart disease than dairy products and red meat.  Kewick and Pawan’s study showed that a group with a 90% fat-consuming diet lost more weight than groups with 90% protein and 90% carbohydrates, indicating that fat does not have to be terrible in the diet.  Fat-free food is not necessarily healthy because the saturated fat is often replaced with sugar, which is being investigated for lowering HDL cholesterol.  Statins are very popular in the US and UK, partially because the Framingham heart study claimed total cholesterol was a risk factor for coronary artery disease.2

I agree with Aseem Malhotra’s article; he supports his point with the literature.  My search of the literature also yielded a recent meta-analysis and a systematic review that support Malhotra’s conclusion that saturated fat is not the major issue.  Patty W Siri-Tarino et al. performed a meta-analysis to see how reducing saturated fat influenced coronary heart disease (CHD), stroke, and cardiovascular disease and concluded that saturated fat does not increase CHD or cardiovascular disease.The discussion of statin therapy is beyond the scope of this post, however the decision to take a statin should be discussed with a medical provider, some patients may still benefit from a statin if they have already had a heart attack.

A patient can eat foods containing cholesterol without getting a heart attack.5  For example, even though egg yolks have cholesterol, they have thirteen essential nutrients, so they should not be automatically eliminated from the diet.  However, it is noteworthy that people typically do not consume only one nutrient per meal.  Saturated fat should be consumed in context of a balanced meal.  Our bodies crave different foods because of the nutrients in them.  Strictly limiting a person to a diet of a few items would not be my primary recommendation for my patients.

This information will slightly change my self-care recommendation because it differs from the dietary standard of care.  If you have high cholesterol and high cardiovascular risk, you may eat saturated fats, dairy products and red meats but should minimize or avoid intake of trans fats and processed meats.  Red meats are not even particularly high in saturated fat.6  O’Sullivan et al. conducted a meta-analysis which demonstrates that large consumptions of the fat-containing foods of butter, cheese, yogurt, and milk “were not associated with a significantly increased risk of mortality compared” with small consumptions.7  Fat-free foods may not be a better choice than regular-fat foods containing saturated fat because the saturated fat is often replaced with sugar.2  Scientists are currently investigating whether sugar leads to low amounts of the “good” HDL cholesterol and raised triglycerides, or fat in the blood.If you have high blood pressure, I encourage you to limit your caffeine intake.

High cholesterol does not appear to increase risk risk for heart disease.  High cholesterol may be falsely accused for heart disease, further studies need to be identified to determine if statins or any cholesterol lowering therapy is beneficial when targeting cholesterol numbers alone.  Involving the patient in discussion of therapy and treating the whole patient vs. numbers from a holistic approach may be more fruitful.

Does this study affect your current perception of treating high cholesterol?  How would you counsel your patients with high cholesterol after reading this post?  What other foods should be avoided in patients with increased cardiovascular risks?

 

References

  1. Available at: http://www.epi.umn.edu/cvdepi/study.asp?id=12. Accessed November 12, 2013.
  2. Malhotra A. Saturated Fat Is Not the Major Issue. BMJ. 2013;347(oct22 1):f6340. Accessed November 1, 2013.
  3. Available at: http://www.medterms.com/script/main/art.asp?articlekey=33979. Accessed November 2, 2013.
  4. Siri-tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr. 2010;91(3):535-46.
  5. Kresser C. The Diet-Heart Myth: Cholesterol and Saturated Fat Are Not the Enemy. Available at: http://chriskresser.com/the-diet-heart-myth-cholesterol-and-saturated-fat-are-not-the-enemy. Accessed November 5, 2013.
  6. Kresser C. New Study Puts Final Nail in the “Saturated Fat Causes Heart Disease” Coffin. Available at: http://chriskresser.com/new-study-puts-final-nail-in-the-saturated-fat-causes-heart-disease-coffin. Accessed November 5, 2013.
  7. O’Sullivan T, Hafekost K, Mitrou F, Lawrence D. Food Sources of Saturated Fat and the Association With Mortality: A Meta-Analysis. American Journal Of Public Health [serial online]. September 2013;103(9):e31-e42. Available from: Business Source Complete, Ipswich, MA. Accessed November 1, 2013.

Dietary Supplements: Encourage or Evict?

Monday, November 18th, 2013

by Elizabeth Ledbetter

The Children’s Hospital of Philadelphia (CHOP) declared in early October 2013 that it will ban most dietary supplements from its pharmacy.1 This is because the U.S. Food and Drug Administration (FDA) does not regulate these products in the same way that they regulate prescription drugs. Because the safety and efficacy of dietary supplements have not been clinically tested by the FDA and cannot be guaranteed, CHOP is doing what they call a “clean sweep” in their pharmacy. They will continue to carry only a select few key vitamins, minerals, and amino acids that have been verified by the U.S. Pharmacopeia Convention (USP).1  

It is difficult to argue with the stance that this hospital is taking because their motivation is respectable. They do not want to recommend products to their patients that have not been thoroughly tested for safety and efficacy. Unfortunately, the decision seems to be a bit rash, and I agree with the author when she writes, “…any approach to healing or prevention should be integrative, malleable, and cautiously open-minded.”1 CHOP seems to be taking a closed-minded approach as they essentially eliminate the potential for disease treatment and prevention through supplements.  In my opinion, dietary supplements do not need to be evicted from our pharmacies just because the same prescription drug tests are not being performed on these products.  Adverse events related to dietary supplements are not near as numerous as those related to prescription drugs.  There were 489 adverse events related to dietary supplements reported in the 2012 fiscal year compared with over 300,000 adverse events related to prescription drugs.2,3

I have worked as a technician in a community pharmacy for two years, and I consistently see a large number of customers purchasing dietary supplements.  I will be the first to admit that I do not believe these customers are doing aimless supplement shopping. When I have encountered patients who need help finding a dietary supplement on the shelf they will inquire, “My doctor told me to purchase some ____________. What aisle is it in?” or, “I’ve been doing some research on __________. Do you carry that here?”  Most often, when a customer is purchasing a dietary supplement, he or she is making the final product choice.  I believe that this responsibility motivates customers to do research on dietary supplements and talk to their doctor about potential benefits and risks.

The stance that CHOP has taken on dietary supplements does not change the recommendations I will make in the future.  CHOP’s stance does, however, motivate me to do thorough research on commonly recommended supplements before I am in the position to make a professional recommendation.  I will be happy to make research-grounded recommendations as a pharmacist, yet I will also remind my patients that they need to be cautious when using dietary supplements because the risks and side effects are not known as well as those of prescription drugs.

Although I disagree with the stance that CHOP has taken in banning dietary supplements, there is evidence that supports the thoughts behind their reasoning. In regards to the concern of regulation, admittedly, dietary supplements have no pre-market approval process.4 They may be freely sold until the FDA objects as a result of adverse event reporting.4 The FDA even states on their website, “Generally, manufacturers do not need to register their products with FDA or get FDA approval before producing or selling dietary supplements.”5 In addition, CHOP decided to ban dietary supplements because their safety and efficacy cannot be guaranteed.  One study that examined clinical study reports suggests that the common dietary supplement dehydroepiandrosterone (DHEA) might even be harmful, as it has shown to lead to increased breast cancer risk in postmenopausal women.6 This study reinforces the threat of potential health risks associated with dietary supplements.

I cannot help but agree with the author of this article when she writes, “It baffles me that the same serious [pharmaceutical research] is not given to natural alternatives, which stand not only to help but may also do less harm.”1 Although we still lack the research necessary to recommend dietary supplements with 100% confidence, it is impossible to ignore the potential benefits they could have in preventing disease. So what is the best option: should pharmacies move toward eliminating their dietary supplement sections?

 References

1 Imus D. Is Philadelphia hospital’s ban on supplements a slippery slope? Fox News. October 23, 2013.  Available at: http://www.foxnews.com/health/2013/10/23/is-philadelphia-hospital-ban-on-supplements-slippery-slope/. Accessed October 31, 2013.

2 U.S. Food and Drug Administration. Number of mandatory adverse event reports from the dietary supplement industry entered into CAERS in the month. 2012. Available at: http://www.accessdata.fda.gov/FDATrack/track?program=cfsan&id=

CFSAN-OFDCER-Number-of-mandatory-adverse-event-reports-from-dietary-supplement-industry-entered-into-CAERS. Accessed November 15, 2013.

3 U.S. Food and Drug Administration. FAERS Patient Outcomes by Year. June 30, 2012. Available at: http://www.fda.gov/drugs/guidancecomplianceregulatory
information
/surveillance/adversedrugeffects/ucm070461.htm. Accessed November 15, 2013.

4 Borneman J. The Regulation of Homeopathic Drugs as Complementary and Alternative Medicine Products: The Role of the Homeopathic Pharmacopoeia of the United States. American Journal Of Homeopathic Medicine [serial online]. Winter2007 2007;100(4):258-264. Available from: Alt HealthWatch, Ipswich, MA. Accessed October 29, 2013.

5 U.S. Food and Drug Administration. Dietary Supplements. August 28, 2013. Available at: http://www.fda.gov/Food/DietarySupplements/default.htm. Accessed October 31, 2013.

6 Stoll B. Dietary supplements of dehydroepiandrosterone in relation to breast cancer risk. European Journal Of Clinical Nutrition [serial online]. October 1999;53(10):771-775. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 30, 2013.

Are Americans Addicted to Oreo’s?

Saturday, November 9th, 2013

By Paul Bicknell, PharmD Student Cedarville University

Over-eating is a significant problem in western culture. For evidence, one need merely look at the ever expanding waistline of its citizenry, but evidence from studies also points to the same conclusion. One study that utilized just over 3.8 million US citizens from around the nation as subjects found that roughly 70% of Americans are either overweight or obese1. Other sources demonstrate the dangerous health effects and economic problems that obesity causes2, 3. However, the cause for overeating remains open to debate to a larger extent, and if cause could be established, people could be assisted in a better way to maintain a healthy weight. One key question is if addiction to food is a factor in our chronic weight gain and how much of a factor it is. Particularly high-fat and high-sugar foods are suspect. This was the case in a study performed by faculty and students at Connecticut College that looked at how rats responded to Oreos as compared to rice cakes and how they responded to an injection of Cocaine or Morphine compared to salt water4. They then examined the rats brains to find that their pleasure centers had been activated by the cookies in a similar way to the drugs4. The researchers argued from this that Oreo cookies are as addictive as cocaine and morphine4.

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The implications of this study were analyzed here in the article “Food Addiction: Does the Oreo Study Prove Anything?” published on WebMD5. This article seems to support the existence of food addiction, but calls into question the ability of the study of a food addiction in rats to predict the same degree of addiction in humans5. The article argues to that end that our biological response to satisfying foods has been evolutionarily beneficial, but can and should be dealt with effectively on a higher level then would be possible for rats since it is not needed to as much of an extent in our well-fed modern society5. At the end is listed a few techniques to try to help deal with food addictions, which includes being mindful of hunger and fullness cues and eating without self-judgment, keeping healthy foods stocked up and only eating high-fat/high-sugar foods in small amounts with a meal, eating meals and snacks only at scheduled times, and trying to eliminate stress which is stated to increase desire for unhealthy foods5.

The study was limited in that it did not present clinical data with human subjects. The human brain is far more advanced then the mouse’s, and humans express a higher level of free thought then mice. The researchers also established a common addiction between the drugs and cookies without comparing them to each other, or even to the same control (drugs compared to salt water, cookies to rice cakes), which makes it hard to establish equality in addiction between the two. The article examining the study also was limited in its reference to outside sources, citing expert opinion a few times and one trial other then the one that was being analyzed.

There is, however, scientific evidence to back up a lot of the suggestions that were made in the article to help deal with food addictions. Free choice has been demonstrated to have an effect in eating habits6, so the higher level of free will in humans would create more control. The benefits of being mindful about eating cues were shown to be effective at reducing tendency to binge eat7. Stress is also demonstrated to be a causal factor that can lead to overeating8, which means attempts to decrease stress may also have a beneficial effect on food addictions.

I would say I agree with most of the content of this article. The helpful tips seem to be in agreement with the primary literature. The other points about making too grand of extrapolations from the data that was collected in the Oreo study seem to also be generally in line with scientific thought. The article gave me ideas for how to counsel on overeating that I intend to implement in my practice, but as a whole, they seem to be pretty consistent with established standards for how to deal with a desire to overeat. I might also add that when a patient faces a desire to eat something unhealthy, he or she could first perform a task that needs to be done, and then eat a very small amount of the desired food as a reward, being sure to only eat a small amount.

Some key question emerges from a discussion about food addiction. What else can be done to help patients deal with their desires to eat too much unhealthy food? How should physicians, pharmacists, nurses, or even government regulating bodies be involved or uninvolved in this task?

 

References:

1.  Kapetanakis, V; et al. OP26 By-State Comparison of Obesity Trends in The Adult Population of the United States of America. Journal of Epidemiology and Community Health. 2012;66:A10-A11 doi:10.1136/jech-2012-201753.026.

2. Wang, Claire; et al. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet. Volume 378, Issue 9793, 27 August–2 September 2011, Pages 815–825.

3. Sorensid, Thorkild; et al. Obesity as a clinical and public health problem: Is there a need for a new definition based on lipotoxicity effects? Biochimica et Biophysica Acta (BBA) – Molecular and Cell Biology of Lipids Volume 1801, Issue 3, March 2010, Pages 400–404.

4.  Student-Faculty Research Shows Oreos Are Just As Addictive As Drugs In Lab Rats. Connecticut College News 10/15/2013.

5.  Jacobsen, Maryann Tomovich. Food Addiction: Does the Oreo Study Prove Anything? WebMD 10/18/2013.

6.  Fleur, S E La; et al. The snacking rat as model of human obesity: effects of a free-choice high-fat high-sugar diet on meal patterns. International Journal of Obesity (27 August 2013) | doi:10.1038/ijo.2013.159.

7.  Kristeller, Jeatn; et al. Mindfulness-Based Eating Awareness Training (MB-EAT) for Binge Eating: A Randomized Clinical Trial. Mindfulnes February 2013.

8. Tsenkova, Vera; et al. Stress Eating and Health Findings from MIDUS, a National Study of US Adults. Appetite Volume 69, 1 October 2013, Pages 151–155