Prilosec and Dementia (Alzheimer's)

A recent study about PPIs suggested that their long term use was associated with increased risk of dementia.

jamaneurol.2015.4791

I had a patient who immediately stopped her prilosec without discussing this with me!

In the study, German researchers simply looked at their health system database of over 70,000 patients over age 75. Using the data they looked at patients who did not have a dementia diagnoses in 2004; then did have one in 2011. Then they looked at medication use in those almost 30,000 who had this diagnosis, and found that, of the 2,800 original patients who had chronic use of PPI there were about 1600 diagnoses of dementia as opposed to expected 1200.

This is an absolute increase of 400 patients in over 30,000 cases. As well, this study depended on the proper diagnosis being sent to the insurance company. Furthermore, patients who took over the counter PPIs, like prilosec could not be controlled for.

Unlike newspaper headlines that stated this was a cause and effect (it certainly was far from it) the researchers stated that the association was interesting and rated further studies.

I prefer not giving any medication if possible. However if there is a clear need for a PPI; such as an ulcer, gastritis, or reflux, the risk of stopping the drug is probably much worse than that of dementia!

Unnecessary and Dangerous Treatments in the Elderly

Many studies are being published that show certain treatments are associated with lower general mortality. Often these benefits are very small, and the old (over 75) are not included.

For example, recent news stories about the SPRINT study published in the New England Journal of Medicine said that the ideal blood pressure now should be 120/80 or lower. However this study only looked at people with increased risk of heart disease. They also did not include diabetics, where another study showed increased risk if we lowered blood pressure to 120 from 140.

These results can be confusing. I would recommend that if the blood pressure can be lowered without complications (like dizziness, falls, etc.) that is ideal. But to be too aggressive can be dangerous.

Many older patients are taking statins such as Lipitor. These drugs have been shown to prevent inflammation in the arteries and decrease the risk of heart disease.However life span is shorter in older individuals, so are these drugs really helping?

Using a model of the U.S. population, researchers estimated the effects of treating all adults aged 75 to 94 with statins for primary prevention over 10 years. They found, based on statistics that there was a definite but small benefit; however a 10-30% increase in risk for adverse events could cancel out the cardiovascular benefits.

So yes, if well tolerated certainly continue statins in the elderly; but with any side effects (most common being muscle pain) we should not hesitate to stop them without too much concern!

Finally, we all know colonoscopy every 10 years after the age of 50 can prevent up to 80% of colon cancer deaths. But when do we stop? When life expectancy is less than 10 years, the risk of screening (as opposed to follow-up for disease) colonoscopy is higher than any potential benefits. For most people this is at age 75; for some in the early 80's; but really never over 85.

Fix Fat Kids - drink water, avoid calories and stay away from fructose!!

Childhood Obesity has many causes, but one of the factors we can actually change is the diet.

Water

Sugar (or corn syrup) flavored drinks are unnecessary and have very high levels of useless calories. Researchers wondered if offering water to overweight children would actually lead to weight loss.

This study in New York was performed in schools that already had removed sugar sweetened drinks from the cafeterias. The study involved 483 public schools that installed “water jets” (large, fast-dispensing, electrically-cooled, water jugs costing about $1000 each) in cafeterias from 2008 to 2013 and 744 schools that did not.

They found small but significant decreases in obesity in the schools offered water; one of the reasons could have been that students in schools with water jets bought about 14 fewer half-pints of fat-free chocolate milk per student per year - a savings of money as well!

Schwartz AE et al., JAMA Pediatr 2016 Jan 19

Fats

In another study researchers looked at whether (in adults) calorie equal low fat or low carb diets were more effective. Interestingly low fat diets led to greater fat loss (not weight loss). However the difference was small. So it is not as critical you avoid carbs to lose weight; as long as you avoid excess calories!

Fructose

fructose is a natural sugar found in many fruits and vegetables. It is also the main sugar found in high-fructose corn syrup; an inexpensive sweetener very often substituted for raw sugar in processed foods. Many pundits have claimed that this is unhealthy. A recent study confirms this.

Forty-three obese U.S. children (age, 8-18 years) with high sugar intake followed a diet for 9 days that replaced added sugar with starch. The goal was to reduce total sugar intake to 10% of daily calories, and fructose intake to 4%, while maintaining baseline caloric intake and weight. All food was provided by the researchers.

After 10 days there was an average weight loss of over 2 pounds (even though they ate the same amount of calories!), as well as decreases in blood pressure, fasting sugar, and cholesterol.

These sugars are bad for you and should be avoided!!

http://onlinelibrary.wiley.com/doi/10.1002/oby.21371/epdf

With common sense we can stop this epidemic!

Video Games and IQ

Most children love to play video games - almost to the extend of addiction. There have been some arguments that this can lead to improved computer literacy. However many studies that I have previously mentioned clearly show that we should be limiting screen time to children.

Now a study reviewed video games. More hours of video gaming were associated with lower verbal IQ as well as some distinct changes in brain chemistry that are sometimes found in autism spectrum disorders. In fact, the authors support the evaluation of autism spectrum and depressive disorders in children who choose video gaming over other age-appropriate behaviors (e.g., socializing).

I would discourage video games before teenage years (when you probably can't control it!).

Takeuchi H et al., Mol Psychiatry 2016 Jan 5

Is Vitamin D dangerous

There has been much publicity about our "low" vitamin D levels and how important it is to test and supplement it. However there is little or no actual evidence that low vitamin D levels are dangerous. In fact, the US Public Health Task Force; whose job is to review the literature, recently (in November) stated:

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults.

http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vitamin-d-deficiency-screening

A recent study in JAMA (JAMA Intern Med. Published online January 04, 2016 doi:10.1001/jamainternmed.2015.7148) examined supplementation of low vitamin D levels in older adults (over 70). They were hoping to find that these would have a lower risk of falls and fractures. However, they found that the group supplemented had 2-3 times the number of falls!

Low Vitamin D has been defined as below 20; and very low below 7-10. In children with growing bones, extremely low Vitamin D can lead to rickets; this is still extremely rare. But there is little evidence that slightly low levels are dangerous in adults/

A small supplement of Vitamin D is probably safe; recommendations of up to 1-2 thousand s units per day are reasonable and unlikely to be dangerous. Like many other things, moderation is the safer way to go!

Germs in Your Intestine - Something New in Medicine!

One of the biggest new stories in medicine is the relationship between the gut bacteria, also known as the microbiotome, and your health.

In previous posts I have mentioned how changes in these germs can increase risk for:

• Obesity
• Asthma
• Diabetes
• Ulcerative Colitis and Inflammatory Bowel Disease
• Melanoma

Now more provocative information has been published.

Microbiotome can affect your response to Cancer Chemotherapy:

In an immune therapy for Melanoma, researchers found that only in the presence of a certain gut bacteria would the therapy be able to cure the cancer!

Anthony L. Komaroff, MD Reviewing Snyder A et al., Science 2015 Nov 27; 350:1031

Also, stool transplants (frozen capsules of stool bacteria) has become the most effective treatment for a potentially fatal colon infection (Clostridium).

The medical has been responding to this news - antibiotic use has decreased by about 25% between 2000 and 2011 in the US,

Thomas Glück, MD Reviewing Frenk SM et al., J Antimicrob Chemother 2015 Oct 12

Look for more news as we learn more about the unique relationship between gut microbiotome and disease. One day forms or probiotics will become adjunctive or primary treatment for many diseases!

Too Many C-Sections

Many people think that the US is doing too many Cesarean sections; for many reasons including malpractice concerns, convenience, and financial gain.

But is this reality? What is the appropriate rate?

When looking at smaller numbers we realize that every delivery is different. However, in a recent study, researchers looked at cesarean delivery rates and morbidity and mortality data from 194 World Health Organization member nations from 2005 to 2012. They found that rates of about 19% were associated with the lowest maternal and neonatal mortality. This is counter to the 15% rate many have suggested as ideal.

So how are we doing? Very poorly. In 2013, the CDC reports that 32.3% of all births were by C-section. In Puerto Rico it was 49%; Louisiana, Florida and New Jersey were close at 38%. The best states were Utah, Idaho, Hawaii and Alaska at rates of 22-25%.

In Canada, the rate was 17% in 1995, but has now climbed to 27%.

So yes, we are doing too many C-sections. If you can. check out your doctors record and willingness to allow labor to proceed when the mother and child are not in danger. Not only are many C-section unnecessary, but they are actually harmful to the mother and child!

JAMA, December 1, 2015, Vol 314, No. 21

http://jama.jamanetwork.com/article.aspx?articleid=2473490