Saturday, November 8, 2014

Chocolate and Cardiovascular Health


    Chocolate is a food that is loved and adored throughout the world.  It provides comfort while imparting a delectable taste that makes one question its’ health promoting properties.  Researchers had observed that the Kuna Indians of Central America consistently maintained a healthy blood pressure throughout their lives (1,2).  They attributed this to the fact that they drank three to four cups of a chocolate drink per day.  As such, chocolate, particularly dark chocolate, has been looked at for the purpose of promoting cardiovascular health (1).  It is said that even a small drop in blood pressure in the hypertensive patient can bring forth positive changes in cardiovascular health(1). 

     Flavonols are the chemical compounds found in cocoa beans that catalyze the production of endothelial nitric oxide which is responsible for this decrease in blood pressure.  These phytochemicals are found in plant based foods like apples, beans and tea in lower concentrations than is present in chocolate.  The higher concentration of flavonols in chocolate  impart the medicinal properties associated with this food.  Furthermore, the density of flavonols in chocolate products is dependent on the processing methods used.  Naturally, dark chocolate is higher in flavonols than is milk chocolate (1,2).  

     A meta-analysis review of 20 different short term studies (approximately 2 weeks in duration) found a significant drop of 2 to 3 mm Hg in blood pressure.  This decrease was noted only in individuals less than 50 years of age.  The results of the studies are questionable due to their short duration(1).  One study that included young healthy people found that consuming 8g of dark chocolate (>70% cocoa) over a month improved vascular functioning(3).  In another review of the health benefits of chocolate a study lasting fifteen years was discussed.  The afore-mentioned study involved men between the ages of 65 and 84 years of age and found those that consumed cocoa products regularly exhibited lower blood pressure(4).  The authors of these reviews suggest more longer term studies for the purpose of arriving to definitive conclusions on the health attributes of chocolate.  It is also stated that many of these studies have been funded by producers of chocolate products which therefore causes one to question the positive findings (1,4). 

     Improved cardiovascular health is only one of the benefits of consuming chocolate that is cited in scientific literature.  Other benefits of chocolate consumption include, but are not limited to, relieving stress by increasing serotonin production, weight management and maintaining oral health.  Despite evidence suggesting chocolate as a health promoting food, moderation in intake should still be exercised(4).  A single serving of a dark chocolate bar every day should be enough to quell your chocolate cravings and promote wellness. 

References

1.)          "Effect of Cocoa on Blood Pressure." Review. The Cochrane Library 8 (2012): 1-81. The Cochrane Collaboration. Web. 5 July 2014.

2.)          Latham, Laura S., Zeb K. Hensen, and Deborah S. Minor. "Chocolate-Guilty Pleasure or Healthy Supplement?" The Journal of Clinical Hypertension 16.2 (2013): 101-05. Web. 5 July 2014.

3.)          Pereira, Telmo, Mariana Vilas Boas, and Jorge Conde. "Dark Chocolate Intake Improves Endothelial Function in Young Healthy People: A Randomized and Controlled Trial." Caridiovascular System 2.3 (2014): 1-6. Web. 5 July 2014.

4.)          Latif, R. "Chocolate/cocoa and Human Health: A Review." Netherlands: The Journal of Medicine 71.2 (2013): 63-67. Print.

Monday, June 16, 2014

Part 2: New Jersey Dietetic Association Annual Meeting


      Vicki Koenig, MS, RD CDN, a Nutrition Consultant to individuals and food companies spoke to the attendees of the annual New Jersey Dietetic Meeting about the usage and benefits of probiotics.  She reviewed some of the history behind the use of probiotics.  The 1908 Nobel Peace Prize winner in the field of Medicine and Physiology, Mr. Elie Metchinkoff is said to have discovered the connection between probiotics and health.  According to Ms. Vicki Koenig, he observed that Bulgarians lived a relatively long and healthy life which he attributed to their consumption of cultured food products.  In fact, Lactobacillus bulgaricus is named after the Bulgarian people.  Lactobacillus, found in the small intestine and Bifidobacteria which inhabits the large intestine are two of the major genera of probiotics noted for their health promoting properties.  Some benefits of the use of bacteria are as follows: improved digestion, lower cholesterol, decrease in allergies and eczema, as well as improvement in the utilization of carbohydrates and proteins.  Contraindications to usage of probiotics are GI bleeding and a immunocompromised system.  The quantity of “good” bacteria in the gut is said to decline with age.   Specific strains should be sought after for certain conditions, therefore, there is no one probiotic fits all according to the speaker. 

     During the poster session there were some interesting pieces of research by Dietetic Interns that were being exhibited.   I will share some tidbits of research from this years College of Saint Elizabeth Dietetic Internship crew.

1.)    Dietetic interns Andrea Ficarra, Alicia Henning and Victoria Kuebler completed a meta analysis review of studies relating to GI disease and nutrition.  Current evidence does not strongly support the use of probiotics in the treatment of IBD, a low FODMAP diet for  treating IBS, or a gluten free diet in caring for diarrhea prominent IBS.

2.)    Another meta analysis review was completed by Jenna Graziano and  Gabrielle Guiliano to investigate the impact of zinc supplementation on hepatic encephalopathy and wound healing. There appears to be a possible benefit of zinc supplementation with hepatic encephalopathy but researchers are not clear on dosage and whether other therapies should be implemented.  Improvement of wound healing was noted whether the patient was zinc deficient or not when receiving supplementation.  Data on this matter is inconclusive at this point.

3.)    Finally, Lindsay Dolashewich reviewed the research between weight control and antipsychotic medications. Long term adherence of 6 months or more to a diet and exercise program showed improvement in weight control and metabolic abnormalities. 

There was much more information that I wish I had the time to share with you!! But, I hope you enjoyed the information I did have time to share! 

Friday, May 30, 2014

Part 1: New Jersey Dietetic Association Annual Meeting


     A couple of weeks ago I attended the annual New Jersey Dietetic Association’s meeting held on May 14th at the Imperia on Easton in Somerset, NJ.   For the most part I was manning the Scholarship Fundraising Raffle table making sure everything was  going well with that part of the event.  Given my duties, I wasn’t able to attend any of the lectures, but ,  I was still able to gather some information  that I hope some of you may find enlightening.

     Ms. Jennifer Stein, MS, RD, a Dietitian with St. Barnabas Health Care discussed,  “The Nutritional Management before and after  Weight Loss Surgery.”  She went over current weight loss treatment modalities, as well as, the evolution of weight loss surgery and nutritional guidelines associated with the surgeries.  Over the years, weight loss surgeries have morphed into what she termed, “metabolic surgeries,” that are done laparoscopicaly and single incisions with shorter hospital stays.  The following table gives a break down on the different surgeries she discussed during her talk:

Restrictive vs. Malabsortive and Restrictive Procedures

Restrictive
Gastric Band
Sleeve Gastrectomy
Weight loss
40 to 50% of excess body weight
>50% excess body weight
Metabolic/hormonal changes
None
Improved diabetes, decreased hunger due to hormonal changes
Nutritional Deficiencies
Most likely not
Vitamin B12; ? others
Risks/Complications
Band slippage, prolapse, weight regain
Leaks, strictures, weight regain
Other
high calorie foods slip through
 
Malabsorptive/Restrictive Procedures
Duodenal Switch
Roux-En-Y Gastric Bypass
Weight loss
>70% weight loss
60 to 80% weight loss
Metabolic/Hormonal Changes
Hormonal changes decrease hunger
Hormonal changes decrease hunger
Nutritional Deficiencies
Fe, Fat soluble vitamins
Vit B12, Fe, Ca, folate
Risks/Complications
Dumping, leaks, ulcer
Dumping, leaks , ulcer

 

     Preoperative care involves diabetes management, smoking cessation and making sure the patient has realistic expectations.  Encouraging exercise, providing protein and MVI, calcium and vitamin D supplementation is also advised.  Postoperative care requires a gradual advancement of the diet.   The first week should be clear liquids, second should be full liquids, the third and fourth week is puree before the final week when  the patient can advance to solid foods.   The only difference is found with the duodenal switch diet which extends to 9 weeks and between the fifth to eighth weeks, the patient is on a semi-soft diet.   All patients undergoing bariatric surgery should have the following supplements:  MVI, calcium citrate, vitamin D and biotin.   Patients who underwent the duodenal switch surgery should also receive fat soluble vitamins. 

     Ms. Cynthia Lowen, a Medical Scientific Liaison with Nestle Health Science, gave a talk entitled, “Nutritional Support of the Critically Ill Patient with Obesity.”  She discussed how obesity, despite it’s associated physical and metabolic derangements, is often missed as a diagnoses.  Other points she talked about were the prevalence of diabetes and nutritional insights into improving outcomes for the critically ill obese patient.  Obesity is currently recognized as a disease associated with a multitude of comorbidities and has behavioral, genetic and environmental causes.  Obese individuals are susceptible to protein energy malnutrition due to increased protein breakdown which leads to a reduction in lean body mass.  Hypocaloric or permissive underfeeding is advised for critically ill patients whose BMI exceeds 30.  11 to 14kcal/kg of actual body weight with protein requirements of 2g/kg IBW for class 1 and !! obesity (BMI of 30 to 39.9) or 2.5g/kg of IBW for class II obesity ( BMI of >40).  Interestingly, she notes that studies have found that providing approximately 8g of leucine a day to critically ill patients can help maintain lean body mass and improve glycemic control.  She states low carb, high protein feedings can have the same effects.  Fish oil is also said to help with outcomes for critically obese patients. 

Stay tuned for some more from New Jersey Dietetic Association’s 2014 Annual Meeting!!

Sunday, March 23, 2014

St. John's Wort Effect on Drug Efficacy


      One of the most studied herbs with regards to drug interactions is St. John’s Wort.   It can be effective in treating mild, moderate and major depression.   Considering many patients who undergo organ transplantation or suffer from HIV and cancer suffer from depression, they many feel inclined to try out St. John’s Wort to treat their mental affliction thinking it to be harmless.  Well, “natural” doesn’t always translate to harmless especially if you are undergoing medical therapy for a variety of medical conditions and there is a potential for an herb-drug interaction.  A decrease in drug efficacy is one of the many ways St. John’s Wort can interact with medications.   St. John’s Wort is comprised of many phytochemicals from flavonoids to napthodianthrones. More specifically there is a phloroglucinol derivative called hyperforin that negatively impacts the pharmacokinetics of certain medications causing a decrease of the drugs plasma concentration in the system thereby disrupting it’s therapeutic potential.  St. John’s Wort preparations with hyperforin concentrations of greater than 1% are often seen to exert negative effects on drug efficacy with certain medications. 

     The isoenzyme CYP3A4 is part of the family of enzymes (otherwise known as  cytochrome P450)  that are involved in drug metabolism.  CYP3A4 with or without the ATP transporter P-glycoprotein when present as  substrates of certain medications are involved in decreasing plasma concentration of these drugs.  These medications include anticoagulants, beta blockers, immunosuppresants, hormonal contraceptives, anti-retrovirals, anti- cancer, and HMG Co-A reductase inhibitors among others.  A cascade of events that effects the genome when hyperforin interacts with a medication causing CYP3A4 and/or P-glycoprotein to be induced  results in decreased drug efficacy. 

     One of the most studied of these interactions with St. John’s Wort involves the immunosuppressant drug cyclosporine.  This medication is given to organ transplant patients to help prevent rejection of the organ.  Cyclosporine is substrate of both CYP3A4 and P-Glycoprotein.  Additionally it has a narrow therapeutic range which also helps encourage the herb-drug interaction.  When St. John’s Wort is taken with cyclosporine it has been observed that plasma concentration of the medication is decreased and dosing adjustments were required.  This is shown to be reversed with discontinuation of St. John’s Wort supplementation. 
   

 
Mannel, Marcus. Drug Interactions with St John’s Wort. Drug Safety.  2004;
27(11): 773-797
Zeping H, Xiaoxia Y, Paul C, et al. Herb-Drug Interactions: A Literature Review. Drugs.2005; 65(9): 1239-1282.
 Izzo A, Edzard E.  Interactions Between Herbal Medicines and Prescribed Drugs: An
Updated Review.  Drugs.  2004; 69(13): 1777-1798. 
Borrelli F, Izzo A.  Herb-Drug Interactions with St John’s Wort (Hypericum
perforatum): an Update on Clinical Observations.  AAPS Journal. 2009; 11(4):
710-727. 
 Wang X, Li J, Su Q, et al.  Impact of the haplotypes the human pregnane X
Receptor gene on the basal and St John’s wort-induced activity of cytochrome
P4503A4 enzyme.  Br J Clin Pharmacol.  2009; (62) 2: 255-261.
 Hiromitsu I, Tsutomu K, Kimiko T.  The recovery time-course of CYP3A after
Induction by St John’s wort administration.  2008; (65) 5: 701-707.
Mueller S, Peszynska J, Uehleke B, et al.  The extent of induction of CYP3A by  St. John’s Wort varies among products and is linked to hyperforin dose.  Eur J Clin Pharmacol. 2006; 62: 29-36.
Mai I, Bauer S, Perloff E, et al.  Hyperforin content determines the magnitude of
The St. John’s wort-cyclosporine drug interaction.  Clinical Pharmacology and
Therapeutics.  2004; (76) 4: 330-340.
Nowack, R.  Review Article: Cytochrome P450 enzyme, and transport protein
mediated herb-drug interactions in renal transplant patients: Grapefruit juice, St.
John’s Wort- and beyond! Nephrology.  2008; 13: 337-347.
Murakami Y, Tanaka T, Murakami H, et al.  Pharmacokinetic modelling of the
interaction between St. John’s wort and ciclosporin A.  Br J Clincal Pharmacol. 
2006; (61) 6: 671-676. 

Sunday, February 23, 2014

Part 2: GNYDA Health and Wellness Conference 2014



     Apparently Diabetic research has come a long way in the past few years and enabled the innovation of novel new pharmaceutical therapies per Dr. Joyce Vergili’s talk on, “Diabetes Medications Update for Healthcare Professionals.”   She went over the different metabolic defects that are associated with diabetes and the therapies that are available.   It so happens that we only had two classes of drugs for diabetes between 1950 and 1994: Sulfonylureas and Insulin.  In just the past few years we have had an influx of new medications being approved by the FDA for treating Type 2 Diabetes.  Metformin remains as first line therapy as long as none of the following contraindications are present: CHF, renal or hepatic impairment.   In addition to insulin resistance and declining beta cell function, she discussed other newly discovered metabolic defects and the types of therapies that have been invented as a result of this new information.  7 of the newest  drugs developed combat what she referred to as the, “Incretin blunting effect.”  The two incretin hormones GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic polypeptide) are secreted from the small intestine when food is ingested.  As diabetes progresses, these hormones are decreased along with insulin.  Incretin is involved in the stimulation of insulin production and inhibition of glucagon secretion.  Moreover, these proteins are degraded by the enzyme dipeptidyl peptidase-4 (DPP-4).   In response the following two classes of drugs have been developed which are depicted in the table below with the medications for each grouping.
Table 1: New Incretin Based Therapies
Class
DPP-4 inhibitors (oral)
GLP-1 Receptor Antagonists (injectable)
Medications
Sitaglipin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Tradjenta)
Alogliptin (Nesina)
Exenatide (Byetta)
Liraglutide (Victoza)
Enenatide extended release (Bydureon)

The other metabolic effect she discussed that has yielded newer therapies is the increased renal glucose threshold.   The normal renal glucose threshold is around 180 mg/dL but increases to approximately 200-250 mg/dL in type 2 diabetes.  The sodium glucose co-transporter-2 (SGLT2) transports glucose into the kidney for glucose reabsorption into the bloodstream.  When maximum capacity of glucose is reached in the kidney the excess is excreted into the urine.  As such the following SGLT-2 inhibitors were developed: Canaglifoxin (Invokana) and Dapagliflozin (Farxiga).   
     Finally, Toby Amidor MS, RD blogger for the Food Network gave us a rundown on what can help draw readers to your blog and why we should blog.   To sum up what she said, she encouraged a website that included lots of photos, was not too lengthy (between 250 to 600 words max) and with a little dose of fun.   She also emphasized the importance of blogging for the Dietetics professional.  After all, Dietitians are the food experts and we are competing with non food experts dishing out nutritional advice in the blogosphere.  She pointed out statistics that showed that the majority of Americans trust food blogs and their recommendations.  Granted there are many successful food bloggers out there that do not have the education Dietitians have when it comes to food and nutrition, this can be problematic.  This point makes it even more important for Dietitians to start blogging, and doing so in a way that attracts readers attention and combat misinformation on the internet related to health and nutrition.    

Friday, February 7, 2014

Part 1: GNYDA Health and Wellness Conference 2014


      This past Saturday (thankfully devoid of the snowstorms and bitter cold we have been experiencing more often than not lately) the GNYDA Health and Wellness conference was held at the University Settlement located in New York City’s Lower East Side.  In years past, it was held at the Cornell Campus of NY Presbyterian Hospital.  Nonetheless, the conference continued its’ legacy of inviting quality speakers exposing attendees to varied areas of Dietetics, as well as, providing an excellent networking opportunity.   This years’ event included presentations about integrative nutrition, blogging, and an update on diabetes. 

     First up was Dr. Jaime Schehr, ND, RD, CDN, a Naturopathic Doctor (a.k.a ND) and Dietitian who practices Integrative Nutrition in New York and Connecticut.  It should be noted that an ND is recognized as a primary care provider in 15 states (by the way, NY is not included in that list).  She differentiated between MNT, Integrative Medicine and Integrative and Functional MNT in the following ways:

 -Integrative Medicine is the synergistic integration of traditional natural healing and modern medicine to promote health and wellness and not just treat the symptoms.

-MNT is reducing risk of complications from already diagnosed conditions like diabetes and high cholesterol.

-Integrative and Functional MNT is focused on the overall health and wellness of the patient by promoting diet and lifestyle modifications.

A healthy gut is the foundation of good health according to Integrative Nutrition practitioners.  Intestinal permeability, which can be negatively impacted by stress, can lead to immune compromise and “stimulate hypersensitivity responses to food and components of gut flora.”  She discussed a situation where a patient of hers had not experienced symptoms of celiac disease until she underwent a stressful period in her life.  Food sensitivities, more often than not, can be detected via elimination diets.   Using eliminating diets are less costly than having the patient undergo blood testing to determine the offending IgG and IgE food antibodies.  Dr. Schehr also described a  4 step gut restoration program that involved Removing foods/medicines that may be harming the gut, Replacing nutrients, digestive enzymes, etc. that may be lacking, Re-inoculate healthy bacteria with the use of pre and probiotics, and finally the last step is to Regenerate using dietary supplements and/or modifying the diet.  Some diets she briefly mentioned are as follows: the anti-inflammatory diet, anti-candida diet, FODMAP diet, Blood type diet, and alkaline diet.  She encouraged dietitians to learn as much as possible about dietary supplements as we are seen as the experts in this area, regardless of the lack of formal education we get in this area.  She suggested a site called Emerson Ecologics which RD’s can join for free as another resource to learn more about Integrative Nutrition. 

     I have more to say!  So stay tuned for the second part of the GNYDA Health and Wellness Conference 2014!!!!

Saturday, January 18, 2014

Family Based Treatment: An Approach Towards’ Treating Eating Disorders in Adolescents




      A recent issue of SCAN’s Pulse (the newsletter for the Sports, Cardiovascular, Wellness and Nutrition DPG group) published an article about eating disorders by Ms. Kerri Heckert, MS, RD, a Dietitian at the Children’s Hospital of Philadelphia.  Eating Disorders (or ED’s) are notoriously known to be difficult to treat.  A recent Huffington Post article on Family Based Treatment (otherwise known as Maudley’s approach) cited that sufferers of anorexia are overwhelmingly young females which range in age from 12 to 26.  Even more alarming was that anorexia is known as the, “deadliest of all mental health conditions.” In the diseases early stages, adolescents coming from loving homes with parent’s who are not overwhelmed with their own mental health issues can benefit from Family Based Treatment or FBT. 
     The primary goal of FBT is to transition these adolescents from a malnourished to a well nourished state.  This is done in a series of 3 phases with 15 to 20 therapy sessions over the course of 9 to 12 months.   Parents are educated on the severity of the medical conditions attributed to the eating disorder.  Not much consideration is given to the cause of the disease, rather the effort is placed on weight restoration.  Through the process of overcoming the illness, the hope is that the patient will gain the appropriate insight to prevent regression. 
     The first phase of the illness usually requires the adolescent to stay home from school with her parents for approximately 2 weeks.   During this time, the child’s meals are constantly supervised by the parents who are involved in every step of the child’s meal planning.  Additionally the parents are asked to compassionately encourage the child to eat and reinforce the idea that it is a necessary part of life.  The second and third phases increase the child’s autonomy during meal times and eventually the majority of the weight required for the patient’s age and height is gained. Studies have shown success with adolescent’s suffering from anorexia but limited yet promising evidence have been reported with Bulimic’s as well. 

Heckert, Kerri. "Family Based Treatment: Getting Parents Involved in the Outpatient Treatment of Eating Disorders." SCAN's Pulse 33 (Jan. 2014): 12-14. Print.References
Pearson, Catherine. "Maudsley Method For Anorexia Treatment Puts Parents In Control Of Their Child's Recovery." The Huffington Post. TheHuffingtonPost.com, 19 Sept. 2013. Web. 18 Jan. 2014.