Thursday, January 18, 2018

Health Tip: Lipoprotein A - The Bad Cholesterol You Can Inherit

The New York Times recently featured a story on Bob Harper, a celebrity fitness trainer for the hit TV show, "The Biggest Loser." He is extremely fit and healthy, and yet had a massive heart attack at age 52. As it turns out, he has a fairly common genetic condition (it is estimated that 1 in 5 Americans have it) in which his body produces too much lipoprotein(a), a type of "bad cholesterol" that promotes blood clots and inflammation, affecting the heart.

It's rather surprising that 20% of Americans have a condition that predisposes for early heart attacks, and yet we don't regularly test for the condition. Why is that? The American Heart Association offers a few explanations: First of all, there is no affordable, widely-available medication available to treat high levels of lipoprotein(a). There are some very expensive monoclonal antibody drugs on the horizon, but they are still undergoing testing and are not widely available or covered by insurance. Niacin may be useful in treating high lipoprotein(a) but clinical trials have not shown a reduction in heart attacks even though it may lower blood levels of the bad cholesterol.

Secondly, lipoprotein(a)'s function in the body is not fully understood, and preliminary studies suggest that very low levels of it, as well as very high levels of it, may be bad for your health. And thirdly, since we don't have consensus about what levels are ideal, and doctors aren't sure what to do with a positive test result, there is understandable hesitation in testing for it. Nevertheless, one thing is certain: high levels of lipoprotein(a) are an independent risk factor for heart disease.

Since your total risk of heart disease increases with every independent risk factor that you have, it makes sense that current recommendations are to lower your overall risk, especially if you have high lipoprotein(a). This includes lifestyle interventions such as regular exercise, maintaining a healthy weight, eating a Mediterranean diet, limiting alcohol intake, reducing stress, quitting smoking, as well as medical options -  taking a cholesterol-lowering statin (such as Lipitor), low dose aspirin to reduce blood clotting, and keeping tight control of your blood pressure and diabetes (if you have them).

If anyone of your close relatives had a heart attack before the age of 55, you may be at higher risk for one as well. Take special care to reduce as many risk factors as you can control and ask your doctor if you may be a candidate for further testing or treatment. It's likely that lipoprotein(a) analysis will become more common in the future. Unfortunately, with unfavorable genetics, even the fittest among us can't reduce our risk of a heart attack to zero. Just ask Bob Harper.

References
https://www.nytimes.com/2018/01/09/well/heart-risk-doctors-lipoprotein.html
http://www.lipoproteinafoundation.org/?page=UnderstandLpa
http://jaha.ahajournals.org/content/5/4/e003597
http://www.heart.org/HEARTORG/Conditions/HeartAttack/LifeAfteraHeartAttack/Lifestyle-Changes-for-Heart-Attack-Prevention_UCM_303934_Article.jsp#.Wl5_CainGHk

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Friday, January 12, 2018

Health Tip: Do You Need A Multivitamin?

Most of us presume that taking a multivitamin every day is a good idea. "Can't hurt, might help" is what we think. And because many of us struggle with getting in enough vitamin-rich fruits and veggies, surely a little supplement is a reasonable "plan B." In fact, roughly one-third of American adults take a multi-vitamin.
Well, the answer to whether or not you need a multivitamin is a little bit complicated. First of all, most Americans get sufficient amounts of nutrients from their (albeit sub-optimal) diets that they are not vitamin or mineral deficient in any clinically significant way. Many years ago vitamin and mineral deficiencies (such as vitamin C - which causes scurvy when absent from the diet, vitamin D - which causes soft bones or rickets, iodine - now added to table salt - can cause thyroid disease or goiters) were a serious public health threat. Nowadays, these diseases are rarely seen in the doctor's office.

That being said, years of research suggest that certain vitamins and minerals are important to supplement under specific circumstances. It would take many book chapters to provide yo
u with all the details and nuances, but I'll try to summarize the most important points here for you.
  • Over 65 years old: As we age, vitamin and mineral deficiencies become more common. Vitamin D, Zinc, and Vitamin B12 are the most common deficiencies in seniors. Vitamin D supplementation is now recommended to improve strength and balance in people over 65. Supplementation has been shown to reduce falls by 19%.
  • Age-Related Macular Degeneration: Those with this particular eye health issue may benefit from vitamin supplements rich in lutein, beta-carotene, Vitamins A, C, E, and minerals zinc and copper. Eye health supplements are commonly known under the trade names Ocuvite and PreserVision and may reduce the risk of vision loss as you age.
  • Malnutrition: If you are eating limited nutrients (either due to extreme dieting, veganism, or perhaps a medical problem such as stomach ulcers or cancer for example) then there is a greater chance that you have vitamin or mineral deficiencies. Those with poor calorie (or poor food quality) intake should ask their doctor if vitamin or mineral supplementation is needed.
  • Wound Healing: Large wounds (from accidents, burns, surgeries or diabetic ulcers, etc.) heal faster if additional vitamin A, C, E and Zinc are supplemented.
  • Pregnancy: If you are pregnant or trying to get pregnant, you should definitely supplement a healthy diet with a pre-natal vitamin that includes folic acid, iron, iodine, and calcium.
  • Chronic anemia or recent blood loss: If you are anemic due to iron deficiency, iron supplementation is appropriate. Keep in mind that oral iron causes significant constipation.
  • Gastric Bypass: If you have had gastric bypass, your absorption of nutrients is likely impaired. Although Vitamin B12 levels are most commonly affected after gastric bypass, folate, zinc, copper, calcium and vitamin D may also be impacted.
  • Heavy Alcohol Use: Folic acid and vitamin B1 and B12 may be low and require supplementation in those who drink alcohol heavily and regularly.
Can a multivitamin do harm?
It's important to know that the Food and Drug Administration (FDA) regulates dietary supplements under a different set of rules than those covering "conventional" foods and drug products. Therefore the contents of multivitamin containers are not independently verified or tested by the US government. It is possible for vitamin companies to sell vitamins and minerals that contain more or less of what is listed on the label.
Quality vitamin and mineral manufacturers voluntarily submit to careful oversight by one of 4 independent companies, and will display their seals (for example US Pharmacopeia, USP, or Consumer Lab) on the bottle.

If your multivitamin causes you to exceed the recommended daily allowance for various vitamins and minerals, you could be at risk for serious side effects. A few examples include:

Calcium - Long term over-supplementation with calcium has been associated with higher rates of heart attacks. The theory is that while calcium is good for the bones, the body may store excess calcium in the walls of heart arteries, causing them to narrow and eventually close.

Vitamin A - High levels of vitamin A can cause symptoms such as nausea and hair loss, and may increase the risk of lung cancer for smokers. There is a risk of birth defects when pregnant women take too much vitamin A.

Iron - In excess, iron can be toxic. Nausea, vomiting, and diarrhea, may progress to seizures, double vision and a rapid heart rate. Iron overdosing is especially dangerous for children.

Manganese - In excess, manganese can cause headaches, muscle cramps, fatigue, and aggressiveness which can then proceed into tremors

Conclusion: Most healthy Americans do not need to take a multivitamin. Specific vitamins and minerals contained in a multi-pill may be helpful when deficiencies are present, but food sources are generally better absorbed. If you have a specific deficiency, supplementing only that vitamin or mineral may be safer than taking a pill that includes more than you need. Look for safety and quality seals of approval from reputable organizations such as Consumer Lab or USP for additional assurance that the vitamin and mineral labels accurately represent their contents.

References
https://ods.od.nih.gov/factsheets/MVMS-HealthProfessional/#en36
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4217039/
https://www.sciencedaily.com/releases/2009/10/091001191659.htm
https://www.ncbi.nlm.nih.gov/pubmed/17209218?dopt=Abstract
https://www.mayoclinic.org/drugs-supplements/iron-supplement-oral-route-parenteral-route/side-effects/drg-20070148

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Thursday, January 4, 2018

Health Tip: New Blood Pressure Guidelines

Should you aim for an even lower blood pressure goal?

There is a hot debate going on right now between physician groups about blood pressure treatment. Specifically, when should we start prescribing blood-pressure lowering medications? When systolic blood pressure is greater than 140/90?  Or perhaps we should begin when it's as low as 130/80 if the patient has one additional risk factor? This is a very important question because we know that high blood pressure puts people at risk for strokes, kidney and heart disease, and even death. So what is the ideal blood pressure and should we give patients more drugs to achieve the goal?

In a bold move, The American Academy of Family Physicians (AAFP) did not endorse The American Heart Association (AHA) and American College of Cardiology's (ACC) new guidelines to begin treatment at the lower pressure of 130/80. The AAFP represents the majority of family physicians in America (about 129,000 of them) while the ACC represents the majority of cardiologists (49,000 strong.)

According to the AHA, the lower treatment threshold would lead to 46 percent of the U.S. adult population being categorized as having hypertension. Using the previous threshold, that figure would be 32 percent of American adults.

Changing the definition of "high blood pressure" therefore, has the potential to add 42 million Americans to the treatment pool for this condition. And before we do that, we should have pretty strong evidence that this will help more than harm, right?

The problem is that although there is evidence of benefit (decreased damage to the heart when hypertension is treated early) the potential harms are less clear. And this is why the AAFP is not endorsing the move, recommending that treatment be a shared decision between patients and their physicians.

As a rehab physician, I treat patients who have injured themselves after falling down. I have found that over-medication is a very common contributor to falls, especially as we age. Patients can feel weak or faint when their blood pressure gets too low, and sometimes well-meaning efforts to keep blood pressure in an ideal range results in an over-shoot. Often times, my patients are also on blood thinners (such as warfarin, aspirin, or newer drugs like dabigitran, apixaban, and rivaroxaban) when they fall, and can bleed fairly profusely, even inside the brain, resulting in very serious and life-threatening damage.

So before you decide to take medicines (or more medicines) for your blood pressure, here are a few things to ponder:
  1. Do you really have high blood pressure? Blood pressure measurement in the doctor's office (when you may feel nervous) sometimes overestimates actual blood pressure. Check your blood pressure on several different days when you're very relaxed at home. Take those results to your doctor to give him or her a sense of your true resting blood pressure.
  2. Can you sufficiently reduce your blood pressure through "natural" methods? Weight loss, regular exercise, and reduced salt intake may reduce your blood pressure enough not to need (more) medications. Weight loss of as little as 10 pounds is enough to make a clinically significant difference in blood pressure.
  3.  Are you at higher-than-average risk for falling? Do you have neuropathy (decreased feeling in your feet), weakness or clumsiness of any kind? Any history of falling? A risky job that makes falling more likely?
  4. Are you taking blood thinners? This greatly increases the potential harm to your body if you do fall down (or are knocked down by a pet) or have another unanticipated event.
Besides the risk of falling, very low blood pressure can occur when you are taking medicine and also become dehydrated or sick. In extreme cases, this combination can be fatal.

So although it's important to manage high blood pressure, over-managing it is not safe. Please talk to your doctor about whether or not you need more medication. Because in my opinion, less is often more!

References
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045868
http://www.acc.org/guidelines/hubs/high-blood-pressure
http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017
https://www.aafp.org/news/health-of-the-public/20171212notendorseaha-accgdlne.html?cmpid=em_AP_20171213
https://www.nhlbi.nih.gov/files/docs/public/heart/hbp_low.pdf

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