Inflammation and Chronic Disease - Part 1: Cardiovascular Disease

Recently, I ran across a method of classifying foods based on their potential to cause inflammation in the body. The significance of this is that inflammation is thought to be the underlying cause for a number of illnesses including diabetes, coronary artery disease, as well as several types of cancer. Even though some people (including the author of the dietary guide that included the Inflammation Rating) are convinced that inflammation is the underlying cause of many chronic illnesses, there is still much to learn about the relationship between these two entities.

What is inflammation? Inflammation occurs as a normal part of the healing process. It is a process that allows the body to remove damaged cells, irritants, or germs following injury, exposure or infection. The classic signs of inflammation include redness, swelling, increased heat, and pain. The inflammatory response is what allows the skin to heal following a cut and is the primary cause of symptoms of the common cold as the body fights off the cold virus. Inflammation is different than infections, which are caused by organisms such as bacteria, viruses, or fungi.

How does inflammation relate to heart disease? Research is ongoing to determine the exact relationship between inflammation and the development of cardiovascular disease. The current theory goes something like this: certain factors, such as obesity, cigarette smoking, and high cholesterol are thought to "injure" blood vessels of the cardiovascular system. This damage can lead to atherosclerosis, the build-up of fat deposits in the walls of blood vessels. In an effort to "fix" the damage, the body's immune system swings into action, producing an inflammatory response. If people continue their unhealthy habits, atherosclerosis and its associated inflammation progresses, ultimately resulting in heart attack or stroke.

How do you measure inflammation in the body? One way of determining if inflammation is present in the body is to perform a blood test for C-reactive protein. This is a substance produced in the liver as a response to inflammation. While elevated C-reactive protein levels have been correlated with the presence of coronary artery disease, other inflammatory conditions can cause elevations of the C-reactive protein also. These include rheumatoid arthritis, certain cancers, and infections.

Who should be tested for C-reactive protein? Some doctors use C-reactive protein levels routinely when assessing patients for the heart disease risk, but this is not a universally accepted practice. The U.S. Preventive Services Task Force has rejected the C-reactive protein as a standard screening test since there is insufficient evidence that reducing the C-reactive protein can reduce the risk of heart attack and stroke. The American Heart Association, on the other hand, recommends a high-sensitivity C-reactive protein test (hs-CRP) as part of routine screening for those with other major risk factors for the development of cardiovascular disease.

Can inflammation be reduced? There is strong evidence that obesity, and especially excess fat in the abdominal region, is a major cause for the development of the metabolic syndrome which includes glucose intolerance (the precursor to diabetes) and elevated cholesterol. These conditions can cause damage to the blood vessels with resulting inflammation. Weight loss, with reduction of abdominal obesity, has been shown to lower C-reactive protein levels and presumably the associated inflammation. Cholesterol-lowering medications called statins also appear to reduce inflammation, perhaps by reducing damage to blood vessels from high cholesterol. Dietary management emphasizing the inclusion of sources of monounsaturated fats (extra-virgin olive oil), omega-3 fatty acids ("oily" fish such as salmon), fruits and vegetables (particularly berries, tomatoes, orange and yellow fruits, and dark leafy greens), with the exclusion of "inflammatory foods", such as margarine, high fat cheese, and marbled beef, has also been proposed as a way to reduce inflammation in the body.

Research is being conducted to see if other medications or dietary interventions can help lower indicators of inflammation and reduce the risk of heart disease. For now, the most critical issue when someone is found to have signs of excessive inflammation as with an elevated C-reactive protein is to control the modifiable risk factors for cardiovascular disease. These include cigarette smoking, high cholesterol, hypertension, obesity, and diabetes.

Calming Restless Leg Syndrome

Occasionally, medical complaints can be so vague or bizarre that it inhibits those suffering such symptoms from reporting them to their doctors. Restless leg syndrome (RLS) is such a disorder. RLS is neurological condition that is characterized by unpleasant sensations in the legs, and an uncontrollable urge to move the legs in an effort to relieve these feelings. It may alternately be described as an aching, burning, "pins and needles," or a "creepy crawly" sensation in the legs. The sensations are particularly bad at rest or when trying to go to sleep. Characteristically, RLS symptoms lessen by moving the legs. People with this disorder try stretching, walking, pacing or exercising in an attempt to combat the uncomfortable sensation in their legs. This irresistible urge to move the legs is where the name comes from. RLS affects up to 10% of the US population, with men and women being equally affected. RLS may begin at any age, but most of those who are affected severely are middle-aged or older. Childhood RLS is estimated to affect almost 1 million school-age children.

What causes RLS? In most cases, the cause of RLS is unknown. A family history of the condition is found in approximately half suffering this condition, suggesting a genetic tendency. In some cases, an underlying medical condition is responsible. These conditions include iron deficiency anemia, diabetes, kidney failure, and pregnancy.

How is RLS diagnosed? There is no single diagnostic test for RLS. The disorder is diagnosed clinically by evaluating the patient's history and symptoms. The four major criteria used to make the diagnosis are: (1) the need or urge to move the limbs, (2) characteristic symptoms that triggered by rest, relaxation, or sleep, 3) relief of symptoms with movement, and (4) symptoms that are worse at night and better in the morning. Laboratory testing may be performed, primarily to evaluate for some of the associated conditions. On occasion, special tests of nerve function or a sleep study is necessary to rule out other conditions

How is RLS treated? When a specific condition is responsible, the best way of treating RLS is to address that underlying problem. This may entail taking iron supplements in someone with iron deficiency anemia or blood sugar management in someone with diabetes. When the cause for RLS is unknown, there is no effective cure. There are treatments, however, aimed at reducing stress and helping muscles relax, which can help with the symptoms.

Lifestyle measures play an important role in alleviating symptoms associated with restless legs syndrome. The most important of these are:

• Avoidance of alcohol, caffeine, and nicotine - The use of tobacco products and the consumption of alcohol or caffeine-containing beverages is known to increase the intensity of RLS symptoms in many sufferers.
  
• Getting Regular exercise - Regular, moderate exercise often helps to relieve RLS symptoms. Exercising excessively, on the other hand, may intensify symptoms. Some sufferers find that light exercise or a stretching routine prior to bedtime is helpful in promoting sleep.
  
• Physical Therapy measures - These include gentle stretching exercises, massage, and taking a warm bath or applying hot packs to affected extremities.
  
• Establish a regular sleep routine - Irregular sleep habits may lead to sleep deprivation and aggravation of symptoms. Important "sleep hygiene" measures to promote restorative sleep include ensuring that the sleeping environment is comfortable and quiet, and going to bed and arising at the same time each day.

Medications are generally reserved for people with RLS who fail to find relief with lifestyle measures. Two medications with FDA approval for the treatment of RLS are pramipexole (Mirapex) and ropinirole (Requip). These are called "dopaminergic agents" because they increase a substance known as dopamine in the brain that is involved in nerve transmission. Other medications that may be used in treating RLS include: 1) carbidopa/levodopa (Sinemet), a drug more commonly used to treat Parkinson's disease, 2) clonazepam (Klonopin) and diazepam (Valium), used to help with sleep and muscle spasms and, 3) gabapentin (Neurontin) and pregabalin (Lyrica), anticonvulsants that can help decrease sensory disturbances such as the "creepy crawly" sensations. Opiate pain medications (Darvon, Tylenol #3, Vicodin, others) are sometimes given, but their addictive potential limits their long-term usefulness. It should be noted also that there are several medications that have been reported to make symptoms of RLS worse. These include OTC antihistamines, such as Benadryl, found in many cold or allergy medications, and anti-nausea medications, like meclizine and Phenergan.

What is the long-term outlook for someone with RLS? In most cases, RLS is a life-long condition that must be managed, rather than cured. This is similar to hypertension, in that it may not go away, but can be controlled. Through a combination of self-care measures and judicious use of medications, most people with RLS can find significant relief of symptoms.

Preventing Falls in Older Adults

It is estimated that each year, one out of three adults over the age of 65 is involved in an unintentional fall. To understand the seriousness of this, here are a few statistics from the Centers for Disease Control:

1. Among older adults, falls are the leading cause of injury related death. In 2009, unintentional fall injuries accounted for about 20,400 deaths.
   
2. In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.
   
3. In 2010, the direct medical cost of falls, adjusted for inflation, was $30.0 billion.
   
4. Over 95% of hip fractures are caused by falls. In 2009, there were 271,000 hip fractures and the rate for women was almost three times the rate for men.
   
5. Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities, which leads to reduced mobility and loss of physical fitness, and in turn increases their actual risk of falling.

Many measures to reduce the incidence of falling in the elderly have been proposed including:

• Assessing for medication side effects or interactions that increase the risk of falling.
  
• Engaging in exercise programs to improve strength, balance, and flexibility.
  
• Wearing proper footwear with low heels and non-slip soles.
  
• Removing home hazards, such as throw rugs, loose electrical cords, and low tables.
  
• Using assistive devices, such as grab rails on the tub and toilet.
  
• Having regular eye exams to check for age-related problems, such as cataracts and glaucoma.
  
• Making sure that walking areas outside the house are clear of obstacles and are well lighted.

While all of these measures seem to have merit, a recent review of 159 studies on interventions to prevent falls in the elderly performed by the Cochrane Collaboration has helped to determine those interventions that are most likely to reduce the number of falls.

Multiple-component exercise. Fifty-nine trials involving over 13,000 participants confirmed the effectiveness of multiple-component exercise programs in reducing falls and the risk of falling. Multi-component exercise programs included a combination of two or more categories of exercise, such as strength training, balance training, tai chi, or cardiovascular activity. Such programs were effective whether delivered in a group setting or at home. Overall, multiple-component exercise programs were more effective than those incorporating only a single component, such as weight training. An exception to this was a program involving the ancient Chinese mind-body practice of Tai Chi which did significantly reduce the risk of falling.

Home safety assessment. This type of intervention, aimed at identifying and addressing potential hazards in the home setting, was found to be effective in reducing rate of falls and risk of falling. Examples of home hazards include inadequate lighting in a hallway, a loose throw rug, and absence of grab rails in the bathroom. Following the assessment, steps are taken to address the identified hazards. There was evidence that these assessments were most effective when performed by Occupational Therapists, rather than by other health professionals or community volunteers.

Effective interventions for specific groups. In elderly individuals with a condition affecting the heart rate known as carotid sinus hypersensitivity, implanting a heart pacemaker significantly reduced falling. Cataract removal surgery was found to reduce the rate of falling in women. In individuals who walk outside when conditions are icy, wearing an anti‐slip shoe device (e.g. Yaktrax® walker) was associated with fewer falls. Individuals involved in outdoor activities sustained fewer falls when they traded their multifocal glasses (i.e. progressive lenses) for single lens glasses. Gradual withdrawal of psychiatric medication and patient-specific modification of drug prescription both reduced falls.

Interventions not found to be effective. In the Cochrane review, interventions of much less or no significance in reducing falls or the risk of falling included: vitamin D supplementation, hormone replacement therapy, programs to increase knowledge about fall prevention, and fluid or nutrition therapy.

In summary, the two interventions from the Cochrane review that stood out for reducing falls in the elderly were multi-component exercise programs and home safety assessments, preferably done by an Occupational Therapist. These and other measures appropriate for specific individuals can help in reducing this largely preventable problem.