Thursday, 25 April 2019

Daily protein needs for seniors still unsettled

A few years ago, the U.S. Food and Drug Administration issued warnings that children and teens who took a common kind of antidepressant might experience suicidal thoughts. The point of the warning was to make sure that parents and doctors paid closer attention to kids taking these medications. But the plan may have backfired.

A national team of researchers led by Christine Y. Lu, an instructor in medicine at Harvard Medical School, tracked antidepressant use among 2.5 million young people between 2000 and 2010. After the FDA’s warnings in 2003 and 2004, use of commonly prescribed antidepressants like fluoxetine (Prozac), sertraline (Zoloft) and others fell by 30% in teenagers and 25% in young adults. During that same period, suicide attempts rose by 22% in teens and 34% in young adults. The researchers concluded that the decrease in antidepressant use, sparked by worries over suicidal thoughts, may have left many depressed young people without appropriate treatment and that may have boosted the increase in suicide attempts. The results were published online this week in BMJ.

While the researchers suggested that the FDA’s warnings are responsible in part for the decline in antidepressant use, the media reaction—and sometimes overreaction—to them made things worse.

“This was a huge worldwide event in terms of the mass media. Many of the media reports actually emphasized an exaggeration of the warnings,” Stephen B. Soumerai, professor of population medicine at Harvard Medical School and a co-author of the study told NPR.
Unintended consequences

Some FDA warnings are right on target. Take, for example, its warning that aspirin should never be given to a child with a high fever. That has surely prevented many cases of a potentially deadly swelling of the brain called Reye’s syndrome. But other warnings may have unintended consequences.

In the late 1990s and early 2000s, primary care doctors and pediatricians became more comfortable diagnosing depression in children and adolescents. During the same period, there was a parallel increase in the number of prescriptions for the class of antidepressant known as selective serotonin reuptake inhibitors (SSRIs). These antidepressants are used most often in children and teens because they are very effective and generally well tolerated.

In 2003, the FDA began to alert doctors that children and teens taking an SSRI might be prone to thoughts of suicide. It added new warnings in 2004 and mandated that SSRIs carry a “black box” warning—so called because it is prominently placed in a black box on the label. According to the BMJ study, the warnings and the media attention that followed led doctors to be more hesitant to prescribe SSRIs to children, teens, and young adults.

It hadn’t been the FDA’s intention to make depression treatment less available to those who needed it. Instead, it wanted doctors to alert patients of the importance of immediately reporting any feelings of wanting to hurt themselves. But some doctors, parents, and youths interpreted the FDA warning differently. The message they heard was that starting an antidepressant increased the risk of suicide.

The FDA was right to sound the alarm about the link between taking an SSRI and suicidal thoughts. There were enough reports of suicide attempts among young people starting an SSRI to justify the warning. But the FDA could have done a much better job of explaining that this did not mean that taking SSRIs caused more suicide attempts.
Don’t give up on depression treatment

When done properly, treating depression with an SSRI is a safe and effective way to rein in this potentially life-changing disease—even in teenagers. That’s even truer when compared to no treatment at all.

Depression treatment does not always mean drug therapy. For mild to moderate depression, talk therapy can work as well as drugs for many people.

If medication is needed, an SSRI is an excellent first choice. But it’s important to heed the message from the BMJ study, and what should have been the message from the original FDA warnings: Anyone with a new diagnosis of depression, and his or her family, need to be alerted to the possibility of suicidal thoughts—even if no drug therapy is started—and to report such thoughts right away. My mom is a little feather of an 84-year-old, quite thin and less than five feet tall. So I wasn’t surprised when her doctor told us recently to make sure she ate more protein, preferably at every meal or snack. Protein is good for building and maintaining muscle and bone. It’s also important for strength and function. A new study aimed to extend the benefits even further, to stroke prevention.

Researchers in China analyzed seven studies that included more than 250,000 participants who ranged in age from their mid-30s to their 80s. They were followed for an average of 14 years. People with the most protein in their diets were 20% less likely to have had a stroke during the study period than those with the lowest amount of protein in their diets. Even more impressive, the risk of stroke went down 26% for every increase of 20 grams of protein in the daily diet. The results were published online today in the journal Neurology.

According to the researchers, if everyone started eating more protein we’d see nearly 1,500,000 fewer stroke deaths per year globally.

That seems like a pretty important finding. Stroke is a major cause of death and disability. But should we buy it? Not yet, cautions Dr. Randall Zusman, a cardiologist at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.

“The findings are provocative and are hypothesis-generating, but I would say there are too many uncontrolled factors in the studies,” he says.

For one thing, other studies have shown no link between dietary protein and stroke. For another, the stroke benefit may be due to what wasn’t eaten. Eating more protein means eating less of something else. Study participants who ate more protein may have eaten less in refined carbohydrates or other potentially harmful foods. That effect was seen in the OmniHeart Trial, which showed that blood pressure, harmful LDL cholesterol, and triglycerides all went down when people ate more protein and fewer carbohydrates.

So maybe we shouldn’t count on the eat-more-protein-reduce-stroke-risk news. But that doesn’t make dietary protein any less vital, especially in older adults who are at greater risk for malnutrition and illness.

How much protein is enough? Current guidelines for adults of any age recommend 0.8 grams of protein per kilogram of body weight. To find out how much you need, multiply your weight in pounds by 0.36. Or use an online protein calculator.

A 160-pound person would need 160 x 0.36 = 58 grams of protein a day. That’s relatively easy to hit: a cup of yogurt for breakfast, a peanut butter and jelly sandwich for lunch, nuts for a snack, and salmon for dinner clock in at 60 grams.

Do older people need more protein than younger ones? “The optimal amount of protein intake to preserve lean body mass, other body functions, and overall health is not well studied in long term research,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital.

That said, it’s clear that some older individuals don’t get enough protein to meet their bodies’ needs, especially if they aren’t getting enough daily calories, says McManus.

So what should you do? Aiming to meet the current recommendations (about 7 grams of protein for every 20 pounds of body weight) is a good first step. You may have to do a little sleuthing of the common foods you eat to find out how many grams of protein are in an average serving. Here are some examples:
Food     Protein (grams)
6 ounces plain Greek yogurt     18
½ cup cottage cheese     14
1 ounce cooked turkey or chicken     9
½ cup cooked beans     9
1 cup of milk     8
1 ounce tuna, salmon, haddock, or trout     7
¼ cup or 1 ounce of nuts (all types)     7
1 egg     6
1 cup cooked pasta     6

Source: Brigham and Women’s Hospital Department of Nutrition

You can see a more extensive list of the amount of protein in food on the U.S. Department of Agriculture’s National Nutrient Database.

What about the type of protein you eat? Mounting evidence shows that reducing animal-based proteins and increasing plant-based proteins is a healthier way to go. You don’t have to replace all of the meat in your diet with plant-based protein. Switching just one serving of red meat per day for poultry, fish, or plant-based protein can make a big difference. One of the findings of the Chinese study in Neurology was that replacing red meat with other protein sources, such as fish, might reduce stroke risk.

But remember that diet, including protein, is just part of the formula for good health and stroke prevention. “The general recommendation for a balanced diet, weight control, salt restriction, daily exercise, and controlling blood pressure and cholesterol still applies,” says Dr. Zusman. I take my pancreas for granted. When I eat, it pumps out insulin. This hormone helps blood sugar get into my cells. When I haven’t eaten for a while, my pancreas makes another hormone called glucagon that prevents my blood sugar from dropping too low.

People with type 1 diabetes don’t have this luxury. But someday they may, thanks to a bionic pancreas developed at Boston University and Massachusetts General Hospital.

In an early test of the device, reported online this week in the New England Journal of Medicine, it helped control blood sugar levels in 20 adults and 32 teenagers with type 1 diabetes who went about their daily lives without the constant monitoring and injecting that’s required with type 1 diabetes.

Right now, this artificial pancreas is essentially an app that runs on an iPhone wirelessly connected to a monitor worn on the abdomen that continually checks blood sugar and two pumps, one for insulin and one for glucagon.

The system work like this: The app on the phone tracks blood sugar. When blood sugar begins to rise, the app signals one pump to release insulin. If blood sugar falls too low, it signals the other pump to release glucagon. This is basically what happens in a healthy body.
Managing type 1 diabetes now and in the future

Type 1 diabetes is what’s known as an auto-immune disease. It occurs when the body mistakenly attacks and destroys healthy cells in the pancreas that make insulin and glucagon. People with type 1 diabetes must constantly check their blood sugar and give themselves insulin. Until recently, checking was done by pricking a finger and placing blood on a small strip inserted in a meter, and insulin was administered with a shot. Today, more and more people with type 1 diabetes are checking blood sugar using a sensor worn on the abdomen and delivering insulin through an implanted pump.

Researchers Edward Damiano, an associate professor of biomedical engineering at Boston University, along with Steven Russell, an assistant professor of medicine at Harvard-affiliated Massachusetts General Hospital, and other colleagues used these components to build their prototype. They have begun a second round of testing, and hope to have a more sophisticated version on the market in five years.

For Damiano, the work is personal: he as a 15-year-old son who has had type 1 diabetes since he was a baby.

Many researchers around the world are searching for a way to cure type 1 diabetes. There’s still no end in sight in that search. But the development of a bionic pancreas represents a bridge that would let people with type 1 diabetes control their blood sugar with less hassle, and more safely, than they do now.

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