Wednesday, 10 April 2019

Nutritional strategies to ease anxiety

Human life expectancy has doubled since 1800. It is a tremendous success story for humankind — but each success brings more challenges to overcome. Because many people are living longer these days, one of the biggest responsibilities of modern medicine is to provide care and treatment for those diseases that become more common with increasing age. One of those diseases is osteoporosis, a thinning and weakening of the bones, which means they break more easily. They can break easily. Osteoporosis can compromise quality of life if it leads to a fracture, and complications of fracture can even lead to death.
Osteoporosis: The “silent enemy”

Osteoporosis is most common in older people, especially (but not only) in women. In many cases, it is first revealed by a sudden fracture — and by the time that happens, it is too late to go back and prevent this dreadful event, which can lead to many complications. According to an article published in the Journal of the American Medical Association, each year Americans suffer from 1.5 million osteoporotic fractures, resulting in more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions. Medicare currently pays for approximately 80% of these fractures, with hip fractures accounting for 72% of the total cost. And because people are living longer (and are therefore more likely to get osteoporosis), the cost of osteoporosis care is expected to rise to $25.3 billion by 2025.
Why not more treatment for osteoporosis?

Despite the availability of cost-effective and well-tolerated treatments that can reduce fracture risk, only 23% of women ages 67 or older who have an osteoporosis-related fracture receive either a bone mineral density test or a prescription for an osteoporosis drug in the six months after the fracture. There are also many available options for preventing and treating osteoporosis before a woman ever experiences a fracture.

Why are so many people, especially women, not receiving osteoporosis treatment? In part because these treatments have faced multiple controversies. Many women have questions when they’re offered preventive treatment, such as: Can calcium supplements increase the risk of heart disease? What will happen to my jawbone if I take this medication? Will this pill give me esophageal cancer? And if I’m not hurting, why do I need treatment at all?

Fortunately, we have some good data to help answer these questions.
What you need to know about osteoporosis prevention and treatment

First, a few points about clinical studies in general. Every study has limitations, and we should keep them in mind while interpreting the results. For example, the population that was studied might be different from the one you belong to, so the results might not be applicable to you. Also, the number of subjects enrolled in the study and any confounding factors — other things that could influence the study results, such as lifestyle factors — should be taken into account when drawing conclusions. Despite these limitations, we have learned quite a lot about the benefits and harms of osteoporosis treatments.

    To date, the consensus is that there has been no proven risk of increased cardiovascular risk with intake of calcium supplements.
    Other studies have examined the risk of damage to jaw tissue with the use of bisphosphonates, one type of medication commonly used to treat osteoporosis. The risk is real, but rare. Most often, it is associated with bisphosphonates given intravenously, not taken by mouth (as most bisphosphonates are). Certain population groups are also at higher risk for necrosis than others. Talk to your doctor about your personal risk for serious bisphosphonate side effects.
    Another common question is whether osteoporosis medications are harmful to your esophagus and the rest of your digestive tract. There is a risk of inflammation of the gut lining, but if you follow the directions carefully while taking the medication and follow up with your physician as directed, the risk is very small.
    Because osteoporosis is a silent disease until a fracture occurs, women often question the need for treatment at all. There are guidelines and tools designed to help you and your doctor decide whether to start treatment, and as a patient, you have the right to know every detail of the treatment options being offered. One of the many available resources to get more information about this disease can be found here.

Your doctor should be able to help you decide by providing all the relevant information and explaining the major side effects of any treatment he or she recommends. From there, you should be an active participant in your own care. Weigh the risks and benefits in your own mind — and with your doctor — before you decide about treatment for osteoporosis. Imagine someone in the throes of a heart attack. If you pictured a man clutching his chest in agony, that’s understandable. At younger ages, men face a greater risk of heart disease than women. On average, a first heart attack — the most common manifestation of this prevalent disease — strikes men at age 65. For women, the average age of a first heart attack is 72.

However, heart disease is the leading cause of death in the United States for both genders. In fact, since 1984, more women have died of heart disease than men each year, although that is partly because women generally live longer than men.

So why do middle-aged men have more heart attacks than women in the same age group? Historically higher rates of unhealthy habits in men — such as smoking and stress — may be partly to blame. In addition, heart disease risk in women appears to rise after menopause; experts believe that in younger women, naturally occurring hormones may play a protective role.

Yet despite considerable gains in the past decade or so, heart disease continues to be underrecognized as the leading cause of death in women, says Dr. Michelle O’Donoghue, a cardiovascular specialist at Harvard-affiliated Brigham and Women’s Hospital. “We need to make sure that women know — and act upon — the signs and symptoms of a heart attack,” she says.
Different heart attack symptoms?

Some studies suggest that during a heart attack, women are more likely to have “atypical” symptoms, such as nausea, dizziness, and fatigue. But other research finds that regardless of gender, the symptoms usually are more similar than different, says Dr. O’Donoghue.

“I think that women may overlook even the classic heart attack symptoms, like chest pain and pressure,” she says. They also tend to minimize their symptoms and delay seeking treatment. In fact, one study that measured how long people waited before seeking treatment for a heart attack found a median delay time of about 54 hours for women, compared with about 16 hours for men. Anecdotal evidence suggests that men often say their wives urge them to go to the emergency room when chest pain strikes.
Heart attack treatment and survival disparities

Earlier this year, the American Heart Association released its first-ever scientific statement about heart attacks in women, which highlights other disparities between men and women. For example, within a year of a first heart attack, survival rates are lower in women than in men — even after accounting for age. Within five years, 47% of women who’ve experienced a first heart attack will die, develop heart failure, or suffer from a stroke, compared with 36% of the men.

A recent study of nearly 50,000 people ages 65 and older who were hospitalized for heart disease (often a heart attack) sheds light on a possible cause for these disparities. The researchers collected data about the advice and treatment people received in the hospital. They found that compared with men, women were less likely to receive potentially beneficial medications such as aspirin and cholesterol-lowering medications, or to receive advice about quitting smoking.

Women also tend to be older and have more health problems when they develop heart disease, and experts have long assumed those differences might in part explain the gender survival gap. But according to the study authors, providing universal, high-quality care at hospital discharge could help to eliminate the death rate disparities. However, research also shows that women are less likely than men to take their prescribed medications. Research is under way to uncover the reasons why.
Trust and verify

The take-home advice for everyone (but especially for women): trust your instincts if you think you might be having a heart attack — call 911 and get it checked out. If you do end up in the hospital, verify with your physician that you’ve received all the advice and prescriptions you need to keep your heart as healthy as possible. Today, more and more children are being diagnosed with concussions. We have evidence that these injuries are occurring more often. The Centers for Disease Control and Prevention reports that between 2001 and 2009, the rate of kids 19 years old and younger seen in the emergency department due to sports- or recreation-related injuries that included a diagnosis of concussion rose by 57%. And sports is only one cause of concussions—there are others including falls and car accidents. In addition, there is greater awareness among physicians, parents, and the “community.” We now have concussion laws in every state, and a much greater realization that “having your bell rung” is not a badge of honor but a significant brain injury.

Doctors in emergency departments and primary care, as well as neurologists and sport medicine specialists, have also become more and more expert at diagnosing concussions. But recognizing concussion is just a start. The ultimate goal is to get these children back to their normal lives. The tricky part is that it can be hard to tell in advance which kids are going to get better fairly quickly and which kids won’t. It is generally believed that about one third of children may experience concussion symptoms that last more than a month. Persistent post-concussive symptoms (PPCS) can impede return-to-learn and return-to-play.

One of the older concussion grading systems labeled children whose symptoms went away in 7 to 10 days as having a “simple concussion.” “Complex concussions” were those where symptoms lasted more than 10 days. By definition, these diagnoses could only be established after the fact.

An article recently published in JAMA proposed a risk scoring system that could make it easier for clinicians to guide families of children who just suffered a concussion going forward. This multicenter study was performed across pediatric emergency rooms throughout Canada. It looked at 46 separate risk factors, and determined that nine of them seemed to help predict the likelihood of PPCS, specifically:

    being female
    age of 13 years or older
    physician-diagnosed migraine history
    prior concussion with symptoms lasting longer than one week
    headache
    sensitivity to noise
    fatigue
    answering questions slowly, and
    4 or more errors on part of a specific test for balance.

Based on these nine risk factors, the authors created a 12-point grading scale that was able to stratify the children into low, moderate and high risk for suffering PPCS. It was reasonably accurate for kids rated as low risk for PPCS (4-11%) and high-risk kids (57-81%). However the risk for children in the moderate risk range was wide (16-48%), which makes it less useful for giving specific advice to families of these children.

It is difficult to know exactly how a child with a newly diagnosed concussion will fare. The children and their families are desperate to know if and when they’re going to get better, and clinical intuition is generally no better than random chance at determining this. If further study shows that the new grading scale works well across a wider spectrum of patients, for example, including those who go to primary care and specialty care clinics (rather than the emergency room), it will be very useful.

Concussion management has come a long way over the past 20 years. Not so long ago, it was really a black box for most clinicians and it is reassuring to think how far we have come. This newly proposed clinical risk score is another tool—one of many we’ve seen emerge—for clinicians to use going forward. It is now incumbent upon us as providers to figure out how to use them most effectively. For example, neurocognitive testing clearly has a role in concussion management, but while it was once thought to be a magic bullet, we now realize that it has to be used judiciously and within context of the overall disease process. This study is another step closer to improving the care of our young patients, and getting them back to school, learning, and a healthy life. According the National Institute of Mental Health, anxiety disorders are the most common mental illness in the United States. That’s 40 million adults—18% of the population—who struggle with anxiety. Anxiety and depression often go hand in hand, with about half of those with depression also experiencing anxiety.

Specific therapies and medications can help relieve the burden of anxiety, yet only about a third of people suffering from this condition seek treatment. In my practice, part of what I discuss when explaining treatment options is the important role of diet in helping to manage anxiety.

In addition to healthy guidelines such as eating a balanced diet, drinking enough water to stay hydrated, and limiting or avoiding alcohol and caffeine, there are many other dietary considerations that can help relieve anxiety. For example, complex carbohydrates are metabolized more slowly and therefore help maintain a more even blood sugar level, which creates a calmer feeling.

A diet rich in whole grains, vegetables, and fruits is a healthier option than eating a lot of simple carbohydrates found in processed foods. When you eat is also important. Don’t skip meals. Doing so may result in drops in blood sugar that cause you to feel jittery, which may worsen underlying anxiety.

The gut-brain axis is also very important, since a large percentage (about 95%) of serotonin receptors are found in the lining of the gut. Research is examining the potential of probiotics for treating both anxiety and depression.
Foods that can help quell anxiety

You might be surprised to learn that specific foods have been shown to reduce anxiety.

    In mice, diets low in magnesium were found to increase anxiety-related behaviors. Foods naturally rich in magnesium may therefore help a person to feel calmer. Examples include leafy greens such as spinach and Swiss chard. Other sources include legumes, nuts, seeds, and whole grains.
    Foods rich in zinc such as oysters, cashews, liver, beef, and egg yolks have been linked to lowered anxiety.
    Other foods, including fatty fish like wild Alaskan salmon, contain omega-3 fatty acid. A study completed on medical students in 2011 was one of the first to show that omega-3s may help reduce anxiety. (This study used supplements containing omega-3 fatty acids). Prior to the study, omega-3 fatty acids had been linked to improving depression only.
    A recent study in the journal Psychiatry Research suggested a link between probiotic foods and a lowering of social anxiety. Eating probiotic-rich foods such as pickles, sauerkraut, and kefir was linked with fewer symptoms.
    Asparagus, known widely to be a healthy vegetable. Based on research, the Chinese government approved the use of an asparagus extract as a natural functional food and beverage ingredient due to its anti-anxiety properties.
    Foods rich in B vitamins such as avocado and almonds
    These “feel good” foods spur the release of neurotransmitters such as serotonin and dopamine. They are a safe and easy first step in managing anxiety.

Are antioxidants anti-anxiety?

Anxiety is thought to be correlated with a lowered total antioxidant state. It stands to reason, therefore, that enhancing your diet with foods rich in antioxidants may help ease the symptoms of anxiety disorders. A 2010 study reviewed the antioxidant content of 3,100 foods, spices, herbs, beverages, and supplements. Foods designated as high in antioxidants by the USDA include:

    Beans: Dried small red, Pinto, black, red kidney
    Fruits: Apples (Gala, Granny Smith, Red Delicious), prunes, sweet cherries, plums, black plums
    Berries: Blackberries, strawberries, cranberries, raspberries, blueberries
    Nuts: Walnuts, pecans
    Vegetables: Artichokes, kale, spinach, beets, broccoli
    Spices with both antioxidant and anti-anxiety properties include turmeric (containing the active ingredient curcumin) and ginger.

Achieving better mental health through diet

Be sure to talk to your doctor if your anxiety symptoms are severe or last more than two weeks. But even if your doctor recommends medication or therapy for anxiety, it is still worth asking whether you might also have some success by adjusting your diet. While nutritional psychiatry is not a substitute for other treatments, the relationship between food, mood, and anxiety is garnering more and more attention. There is a growing body of evidence, and more research is needed to fully understand the role of nutritional psychiatry, or as I prefer to call it, Psycho-Nutrition.

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