28/04/2019

Fluids, cool air key to avoiding heat stroke

The answer is more friend than foe, if the fish oil comes from food sources rather than supplements.
Omega-3s in balance

What’s so special about fish oil? It’s loaded with omega-3 fatty acids. These must come from food, since our bodies can’t make them.

The two key omega-3 fatty acids are docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Fatty fish like salmon, mackerel, and sardines are rich in these omega-3s. Some plants are rich in another type of omega-3 fatty acid, alpha-linolenic acid, which the body can convert to DHA and EPA. Good sources of these are flaxseeds, chia seeds, walnuts, pumpkin seeds, and canola oil.

Omega-3 fatty acids play important roles in brain function, normal growth and development, and inflammation. Deficiencies have been linked to a variety of health problems, including cardiovascular disease, some cancers, mood disorders, arthritis, and more. But that doesn’t mean taking high doses translates to better health and disease prevention.

Fish oil supplements have been promoted as easy way to protect the heart, ease inflammation, improve mental health, and lengthen life. Such claims are one reason why Americans spend more than $1 billion a year on over-the-counter fish oil. And food companies are adding it to milk, yogurt, cereal, chocolate, cookies, juice, and hundreds of other foods.

But the evidence for improving heart health is mixed. In November 2018, a study reported in the New England Journal of Medicine found that omega-3 fatty acid supplements did nothing to reduce heart attacks, strokes, or deaths from heart disease in middle-age men and women without any known risk factors for heart disease. Earlier research reported in the same journal in 2013 also reported no benefit in people with risk factors for heart disease.

However, when researchers looked at subgroups of people who don’t eat any fish, the results suggested they may reduce their cardiovascular risk by taking a fish oil supplement.

Evidence linking fish oil and cancer has been all over the map. Most research, including the 2018 study cited above, has not shown any decreased risk of cancer. However, some earlier research suggested diets high in fatty fish or fish oil supplements might reduce the risk of certain cancers.
Take home message

How food, and its component molecules, affect the body is largely a mystery. That makes the use of supplements for anything other than treating a deficiency questionable.

Despite this one study, you should still consider eating fish and other seafood as a healthy strategy. If we could absolutely, positively say that the benefits of eating seafood comes entirely from omega-3 fats, then downing fish oil pills would be an alternative to eating fish. But it’s more than likely that you need the entire orchestra of fish fats, vitamins, minerals, and supporting molecules, rather than the lone notes of EPA and DHA.

The same holds true of other foods. Taking even a handful of supplements is no substitute for wealth of nutrients you get from eating fruits, vegetables, and whole grains.

What should you do if you currently take fish oil? If your doctor prescribed them—they are an approved and effective treatment for people with high blood triglyceride levels—follow his or her instructions until you can have a conversation about fish oil.

If you are taking them on your own because you believe they are good for you, it’s time to rethink that strategy. If you don’t eat fish or other seafood, you might benefit from a fish oil supplement. Also you can get omega-3s from ground flaxseed or flaxseed oil, chia seeds, walnuts, canola oil, and soy oil. One to two servings per day can help you avoid a deficiency of omega-3s.

Following food author Michael Pollan’s simple advice about choosing a diet may be the best way forward: “Eat food. Not too much. Mainly plants.” Over the years, I’ve written and edited many articles for medical journals. I have to say I’m now finding it a bit odd to be on the flip side as the subject of such an article (along with 285 other people). A couple years ago, I volunteered to take part in a clinical trial testing whether an old, aspirin-like drug called salsalate could help control blood sugar in people with type 2 diabetes. The results of that trial, called TINSAL-T2D, are reported in the current issue of Annals of Internal Medicine.

All 286 volunteers were given blue pills to take every day for nearly a year. Half of us got pills containing salsalate; the others got placebo pills. Over the course of the trial, those in the salsalate group had lower blood sugar levels, and some were even able to reduce dosages of other diabetes medications they were taking.

“We were very pleased with the findings of the TINSAL-T2D study,” said lead author Dr. Allison B. Goldfine, associate professor of medicine at Harvard-affiliated Joslin Diabetes Center. “They indicate that salsalate, a drug that has been marketed for over 40 years for the treatment of arthritis, could be an inexpensive additional therapeutic option to treat patients with diabetes.”
Inflammation and diabetes

Salsalate is an old drug that’s closely related to aspirin. Use of these drugs and their natural precursor use can be traced back at least 3,500 years. Today, salsalate is used to treat arthritis pain. One advantage it has over aspirin and other nonsteroidal anti-inflammatory drugs is that it doesn’t irritate the digestive tract.

No one knows exactly how salsalate helps control blood sugar. But its effectiveness supports the idea that inflammation plays a role in type 2 diabetes. In addition to improving blood sugar control, salsalate lowered counts of white blood cells involved in inflammation. It also boosted levels of adiponectin, a potentially heart-protecting protein made by fat cells.
Not ready for prime time

The TINSAL-T2D results are promising. Salsalate helps lower blood sugar. It has a good safety profile. It has been used for years for other purposes. And it is relatively inexpensive. But it won’t be prescribed any time soon for people with type 2 diabetes.

Three safety blips appeared during the trial. 1) Those taking salsalate gained an average of two pounds during the trial while those taking the placebo lost about a pound. Over time, extra weight can lead to poorer blood sugar control. 2) Harmful LDL cholesterol rose about 10 points in the salsalate group, compared to no change in the placebo group. 3) The amount of a protein called albumin excreted in the urine was higher in the salsalate group. That could be a sign of potentially worrisome changes in the kidneys.

What we really need to know about a new or repurposed drug is how its long-term benefits and risks stack up against each other. The relatively short length of the TINSAL-T2D trial and the relatively small number of volunteers don’t provide enough information on that. According to the researchers, more work is needed before salsalate can be recommended for widespread use by people with type 2 diabetes.

Some of that work is already underway. The TINSAL-CVD study is testing salsalate’s effects on cholesterol-filled plaque in the arteries that nourish the heart. (Heart disease is the leading cause of death among people with type 2 diabetes.) If that study shows that salsalate slows the growth or spread of plaque, “a larger and longer outcome study would be needed before the FDA would provide a new indication for the use of salsalate beyond its current indication for pain management in patients with arthritis,” said Dr. Goldfine.
A personal note

I never found out whether I was taking salsalate or a placebo. It never really mattered. But I got a lot out of taking part in TINSAL-T2D. I received excellent diabetes care from an engaged diabetes specialist (Dr. Goldfine) and trial coordinator (Kathy Foster). I experienced first-hand some tests I’ve often written about. I learned that I had a late-onset type 1 diabetes called latent autoimmune diabetes of the adult, rather than type 2 diabetes. And it felt good to take part in medical research, not just write about it.

Thousands of clinical trials are in need of volunteers. If you are interested in participating in one, take a look at ClinicalTrials.gov, put together by the National Institutes of Health. It lists the nearly 70,000 clinical trials now underway in the United States. The sudden hospitalization yesterday of Teresa Heinz Kerry, wife of U.S. Secretary of State John Kerry, while vacationing on Nantucket Island is an unfortunate reminder that illness can happen at any time—even during a vacation.

Heinz Kerry was taken by ambulance on Sunday afternoon to Nantucket Cottage Hospital. She was accompanied by her husband. After being stabilized, she and the Secretary of State were flown to Massachusetts General Hospital in Boston. As of Monday morning, neither the hospital nor Heinz Kerry’s family has commented on the nature of her illness. News reports say she is in critical but stable condition.

Heinz Kerry’s situation highlights the value of electronic medical records, and the hazards of not having, or being able to access, medical information when you are travelling or on vacation.

The Patient Protection and Affordable Care Act, signed into law by President Barack Obama in 2010, mandates the development of secure, comprehensive electronic medical records by next year. Some hospitals and physicians already have electronic medical records for their patients. These records make it possible to share information with doctors across town, or across the globe. Most people don’t yet have their medical information in an easily shareable format.

In fact, it’s a safe bet to assume that if you are away from home and need emergency medical care, doctors won’t have access to your medical records. So it’s a good idea to carry at least a list of your (and your family members) medical problems, medications and doses, recent treatments, allergies, and other important health information. Keep it safe and secure, but make sure someone else knows where to find that list if you aren’t able to access it.

A potentially life-threatening event can happen at any time—even if you are in good health. Vacations are no exception. In addition to your list, it’s also a good idea to have completed, signed, and have witnessed an advance directive and health care proxy.

If you haven’t prepared an advance directive and you can’t communicate your preferences for treatment, medical choices will be left to worried relatives or to a doctor or guardian appointed by a judge, none of whom may have a clear understanding of your values, beliefs, and preferences. An advance directive lets you decide the kind of care you want to receive. A health care proxy lets you designate the person who can speak for you when you are unable to communicate. Summer’s heat is as predictable as winter’s chill. Heat-related illnesses—and even deaths—are also predictable. But they aren’t inevitable. In fact, most are preventable. Staying hydrated is the key.

No matter what the season, your body functions like a furnace. It burns food to generate chemical energy and heat. Some of the heat is used to keep your body temperature in the high 90s. The rest you have to get rid of. The body has two main ways of getting rid of excess heat:

Radiation. When the air around you is cooler than your body, you radiate heat to the air. But this heat transfer stops when the air temperature approaches body temperature.

Evaporation. Every molecule of sweat that evaporates from your skin whisks away heat. But as the humidity creeps above 75% or so, there’s so much water vapor in the air that evaporation becomes increasingly difficult.

Most healthy people tolerate the heat without missing a beat. It’s not so easy for people with damaged or weakened hearts, or for older people whose bodies don’t respond as readily to stress as they once did. Damage from a heart attack can keep the heart from pumping enough blood to get rid of heat. A number of medications can limit the body’s ability to get rid of excess heat. These include beta blockers, which slow the heartbeat; diuretics (water pills), which can make dehydration worse by increasing urine output; and some antidepressants and antihistamines, which can block sweating. A stroke, Parkinson’s disease, Alzheimer’s disease, diabetes, and other conditions can dull the brain’s response to dehydration.
Heat-related illnesses

There are three different levels of heart-related illness:

Heat cramps. These painful muscle spasms are usually triggered by heavy exercise in a hot environment. Inadequate fluid intake is usually the culprit. The remedy: slow down, tank up with water, stretch and gently massage the tight muscle, and get out of the heat.

Heat exhaustion. When body temperature begins to climb, physical symptoms such as weakness, headache, nausea, muscle cramps, profuse sweating, and flushed, clammy skin may appear. Heat exhaustion also affects mental clarity and judgment, which may appear as confusion or lethargy. Drinking water is essential. A cool shower or bath, ice packs to the skin, or other strategies to lower body temperature are also important.

Heat stroke. There are two distinct forms of heat stroke. Classic heat stroke tends to affect people who can’t escape the heat, or can’t physically cope with it. Exertional heat stroke strikes individuals who do vigorous physical activity in the heat—youthful football players at a summer training camp, firefighters battling a summer blaze, Marine recruits, and weekend warriors. Heat stroke is a medical emergency. It starts out looking like heat exhaustion, but its symptoms are more severe, and they progress more quickly, as lethargy, weakness, and confusion evolve into delirium, stupor, coma, and seizures. Body temperature rises drastically, often exceeding 105° or 106°. Heat stroke is a killer because it damages the heart, liver, kidneys, brain, and blood clotting system. Survival depends on prompt transfer to a hospital for aggressive treatment.
Warning signs of heat illness

Heat-related trouble ranges from irritating problems such as muscle cramps to heat exhaustion and the potentially deadly heat stroke. It can be hard to tell where heat exhaustion ends and heat stroke begins. Both can be mistaken for a summer “flu,” at least at first. Be on the lookout for:

    nausea or vomiting
    fatigue
    headache
    disorientation or confusion
    muscle twitches

If you think you are having heat-related problems, or if you see signs of them in someone else, getting to an air-conditioned space and drinking cool water are the most important things to do. If these don’t help or the symptoms persist, call your doctor or go to a hospital with an emergency department.
Beat the heat

Even during the nastiest heat wave, the numbers are in your favor—relatively few people have heat strokes, and fewer die. Some simple choices can help you weather the weather. An ounce of prevention will go a long way, but for heat-related illnesses, a quart is even better.

Drink to your health. The lower your coolant level, the greater your chances of overheating. Unfortunately, staying hydrated isn’t always easy. Stomach or bowel problems, diuretics, a faulty thirst signal, or low fluid intake can all interfere. On dangerously hot and humid days, try downing a glass of water every hour. Go easy on sugary soda and juice, since they slow the passage of water from the digestive system to the bloodstream. And don’t rely on caffeinated beverages or alcohol for fluid because they can cause or amplify dehydration.

Take it easy. Turn procrastination from a vice to a virtue by putting off exercise or other physical activity until things cool down. Evening and early morning are the best times to get out. If you do exercise, drink more than you usually do.

Cool is cool. Chilled air is the best way to beat the heat. Fans work, but only to a point—when the air is as warm as you are, sitting in front of a fan is about as helpful as sitting in front of a blow dryer. If you don’t have an air conditioner, spending an hour or two in an air-conditioned movie theater or store, or with an air-conditioned neighbor, can help. So can a cool shower or bath, or putting a cold, wet cloth or ice pack under your arm or at your groin. Do-it-yourselfers, take heart. Here’s something else to do at home that can have a substantial benefit on your health: measure your blood pressure. It’s easy, inexpensive, and helps control blood pressure better than visits to the doctor.

The latest evidence for the benefits of home blood pressure monitoring comes from researchers in Minnesota. They studied 450 people with hypertension, more commonly known as high blood pressure. All had blood pressures higher than deemed healthy—above 140/90, or above 130/80mmHg if they had diabetes or kidney disease.

About half of the volunteers were given home blood pressure monitors capable of electronically sending readings to a secure website. After being shown how to use their monitors, the volunteers were asked to send six readings each week. That information was assessed by pharmacists, who could adjust medications if needed and offer advice on lifestyle changes that could improve blood pressure. The other volunteers received usual care from their primary care providers.

At every step of the way, people in the home monitoring group had more success getting their blood pressure under control than people who had received only usual care. At the end of the trial, 72% of those doing home monitoring had their blood pressure under control, compared to 57% of the usual care group. The benefits persisted six months after the program had ended.

The results, published today in JAMA, are similar to the findings of previous studies on home blood pressure monitoring. But, according to the researchers, this is the first time people with both uncontrolled blood pressure and other conditions (such as diabetes) have been studied in such a program, and the first time results were measured after the formal monitoring program had ended.

“More frequent blood pressure monitoring allows more opportunities to detect blood pressure that is higher than the desired range. That may trigger more intensive treatment of elevated blood pressure,” says cardiologist Dr. Deepak Bhatt, a professor at Harvard Medical School. In other words, if you stay on top of it, you’ll do a better job of treating it.

An editorial accompanying the report said that the study “demonstrates how to improve blood pressure control by making hypertension management more like modern banking: accessible, easy, and convenient.”
The need for home monitoring

The Centers for Disease Control and Prevention reports that 1 in 3 adults in the United States has high blood pressure, and half of them don’t have it under control. High blood pressure increases the risk for heart disease and stroke, the leading causes of death in the United States.

Even though the American Heart Association and other organizations have called for greater use of home blood pressure monitoring, it isn’t yet widespread. One reason is that insurance coverage for such programs still lags. Another is that full-fledged efforts like the one in Minnesota could cost $1,350 per person.
Monitoring at home

Discover the secrets to lowering your blood pressure and reducing your risk of heart attack, stroke, and dementia!

But you don’t need a special program. You can buy a good home blood pressure monitor at a pharmacy or online merchant for anywhere from $50 to $100. (Ask if your insurance company will cover the cost.) A few things to look for:

    an automatic monitor that doesn’t require a stethoscope (it’s easier to use)
    a monitor that takes the blood pressure reading using a cuff that fits around the upper arm;
    a read-out large enough for you to see the numbers;
    a seal from an organization such as the British Hypertension Society, International Protocol for the Validation of Automated BP Measuring Devices, or Association for the Advancement of Medical Instrumentation (AAMI).

Ask your doctor, nurse, or pharmacist for help calibrating your monitor and learning how to use it.

How often should you check? At first, take your blood pressure twice a day for a week. The best times are early in the morning (before you have taken any blood pressure medications) and again in the evening. After you’ve done this for a week, once or twice a month—or whatever your doctor recommends—is fine.

“It can be a very effective way to see if blood pressure medications are doing the trick. It can also be useful to monitor for the side effect of blood pressure that is too low. Just remember that home monitoring should not be used as a substitute for regular physician check-ups, especially for patients with poorly controlled blood pressure,” says Dr. Bhatt.

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