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Low vitamin D doubles total mortality and dementia rates

Sep 10, 2016Jul 6, 2016 kaitiscotland5 Comments

Being severely deficient in vitamin D is associated with a doubling of the risk of dementia according to a US study published in Neurology.

The Cardiovascular Health Study ran from the 1990s and tracked 1658 ambulatory citizens with no history of dementia or cardiovascular or cerebrovascular disease.

After a five year follow up time those who had vitamin D levels below 25 nmol/L had increased rates of dementia 2.2 times that of people who had levels over 50 nmol/L.

Researchers say that there are vitamin D receptors in the brain and vitamin D is thought to enhance macrophages that clear amyloid from the brain cells and reduce neuronal cell death.

(Based in article by Michael McCarthy in BMJ 16 August 14).

A combined European and US study showed that total mortality was increased by 57% for older adults with vitamin D levels below 25 nmol/L. Cardiovascular deaths and cancer deaths were increased in a dose responsive manner.

(Based on and article by Stephen Robinson GP News 23 June 14)

Bizarrely the researchers didn’t think of the obvious solution, advise upping sun exposure or taking supplemental vitamin D, but decided that what this meant was that ill people were often stuck indoors and that was why they had low vitamin D levels.

The US study above does seem to contradict that view since all participants were ambulatory and had no known cardiovascular or cerebrovascular disease at the start of the study. In my own practice in the west of Scotland most patients of all ages had very low levels of vitamin D. All walked into the surgery but had conditions that could have been affected by low vitamin D levels. The only patients who had levels over 50 nmol/L were taking supplements, cycled outdoors all year round, or used sunbeds.

Jovina cooks Italian: Fresh herbs and summer squash chowder

Sep 7, 2016Jul 29, 2016 kaitiscotlandLeave a comment

Cooking With Fresh Herbs

by Jovina Coughlin

Don’t let your herbs go wild in the garden or get moldy in the refrigerator. There are lots of way to incorporate them into your recipes.

A general guideline for using fresh herbs in a recipe is to use 3 times as much as you would use dried herbs.

Wash herbs when you are ready to use them. Shake off moisture or spin dry in a salad spinner. Pat off any remaining moisture with clean paper towels.

For most recipes, unless otherwise directed, mince herbs into tiny pieces. Chop with a chef’s knife on a cutting board or snip with a kitchen scissors.

Unlike dried herbs, fresh herbs are usually added toward the end in cooked dishes to preserve their flavor.

Storing Herbs

Fresh herbs can be stored in an open or a perforated plastic bag in your refrigerator for a few days.

After washing, you can mince the herbs and place them halfway up in the sections of an ice-cube tray. Cover herbs with cold water and freeze until solid.

Transfer the frozen cubes to a freezer bag. Drop them into soups, stews and sauces as needed.

Some Other Ways To Use Herbs

If you love a big, green salad, add fresh herbs to the mix.

Add a big handful of fresh herbs to a basic mixture of equal parts sugar and water, bring to a boil, stir and then remove from the heat. Once completely cooled, strain out the herbs (discard) and use the simple syrup to sweeten iced coffee or tea and cocktails.

Fresh herbs are a perfect in salad dressings and vinaigrettes. They round out the fatty and sharp flavors from the oil and vinegar.

Combine finely chopped herbs and room-temperature butter to make a spread that compliments bread or cooked meat or vegetables.

Summer Squash Chowder

Servings: 4-6
Time: 40mins
Difficulty: easy
Print

Ingredients

3 tablespoons butter
3 medium courgettes and 2 medium patty pan squash, diced
1 large sweet (Vidalia) onion, chopped
2 celery stalks, diced
8 cups Summer Vegetable Stock (corn cob stock) (recipe here)
1 clove garlic, minced
1 tablespoon minced fresh thyme
1 tablespoon minced fresh sage
1 tablespoon minced fresh basil
1 teaspoon minced fresh oregano
Salt and freshly ground pepper
Juice of 1 lemon
1 cup fresh corn kernels
Sour cream for garnish

Directions

Heat the butter in a large saucepan or stockpot; add the garlic, celery and onion. Saute for 5 minutes. Add the squash and lightly salt the vegetables. Saute for an additional 5 minutes.

Add the stock and 1 teaspoon salt, bring to a boil, reduce heat and partially cover and cook for 25 minutes. Puree the soup with a hand immersion blender until smooth.

Taste and season with additional salt and pepper, if needed. Stir in lemon juice, corn and herbs. Simmer for 5 minutes. Serve in individual soup bowls topped with a tablespoon of sour cream.

Allow 12-15g of net carbs per serving.

Low carb high fat diets: useful for cancer prevention?

Sep 4, 2016Jul 12, 2016 kaitiscotlandLeave a comment

There is some evidence that a low carb diet can help prevent cancer and also improve the outlook for people who already have the condition. Here are too sites that discuss the issue.

Dr Mercola provides an article.

http://articles.mercola.com/sites/articles/archive/2016/06/11/nutrition-influences-cancer.aspx?utm_source=dnl&utm_medium=email&utm_content=art1&utm_campaign=20160611Z1&et_cid=DM107622&et_rid=1525493561

Dr Gary Fettke appears on video.

https://www.youtube.com/watch?v=qa5Bcm8T9nU

Half of Cancer Deaths are Preventable

Sep 1, 2016Jul 6, 2016 kaitiscotlandLeave a comment

Harvard researchers find as many as 40 percent of cancer cases, and half of cancer deaths, come down to things people could easily change.

Many Americans often worry about whether chemicals, pollution or other factors out of their control cause cancer, but a new analysis shows otherwise: people are firmly in charge of much of their own risk of cancer. As we get older, our risk goes up, which could come from doing the same bad habits over a long period of time. The same can be said for being diagnosed with diabetes and prediabetes. Eating one large order of French fries will not increase your risk for cancer or diabetes, but eating two orders a week over 40 years would be over 4,000 orders, or over 2,000,000 calories and 259,000 carbohydrates, which can certainly be injurious to your health.

The team at Harvard Medical School calculated that 20 to 40 percent of cancer cases, and half of cancer deaths, could be prevented if people quit smoking, avoided heavy drinking, kept a healthy weight, and got just a half hour a day of moderate exercise. They used data from long-term studies of about 140,000 health professionals who update researchers on their health every two years for the analysis, published in the Journal of the American Medical Association’s JAMA Oncology.

“Not surprisingly, these figures increased to 40 percent to 70 percent when assessed with regard to the broader U.S. population of whites, which has a much worse lifestyle pattern than our cohorts,” wrote Dr. Edward Giovannucci of Harvard Medical School. The analysis was simple. They broke the 140,000 people into two groups: those with a healthy lifestyle, and everyone else. The healthy lifestyle definition was based on a large body of studies that have shown what personal habits are linked with higher or lower risks of cancer. They include not smoking; drinking no more than one drink a day for women, two drinks a day for men; keeping a healthy weight, defined as body mass index of between a very slender 18.5 and a slightly overweight 27.5; and getting the equivalent of just over an hour of vigorous exercise or two and a half hours of moderate exercise a week.

Heavy drinking raises colon, breast, liver and head and neck cancer rates. Obesity raises the risk of esophageal, colon, pancreatic and other cancers. Smoking causes 80 to 90 percent of lung cancer deaths. Only about 28,000 of the people analyzed qualified as following a healthy lifestyle. When the rates of cancer in their group were compared to rates in the rest of the volunteers, the differences were clear.

The purpose of the study was to estimate the proportion of cases and deaths of carcinoma (all cancers except skin, brain, lymphatic, hematologic, and nonfatal prostate malignancies) among whites in the United States that can be potentially prevented by lifestyle modification.The incidence rates of cancer were 463 per 100,000 for women in the “healthy” group, versus 618 per 100,000 for those not meeting the healthy goals. For men, it was 283 per 100,000 who met the healthy lifestyle goals versus 425 among those who did not. And these were health professionals, who should at least try to be healthier. When Giovannucci compared the healthy group to the general, white, U.S. public, the differences were even bigger. Plus, they didn’t add in other known factors, such as eating a healthy diet rich in fruits and vegetables, although they said those who followed the other healthy patterns did tend to eat better, also.

“These compelling data together with the findings of the current study provide strong support for the argument that a large proportion of cancers are due to environmental factors and can be prevented by lifestyle modification.” By “environmental,” they mean non-genetic causes. To a scientist, environment includes diet, exercise and other factors.

89,571 women and 46,339 men from 2 cohorts were included in the study: 16,531 women and 11,731 men had a healthy lifestyle pattern (low-risk group), and the remaining 73,040 women and 34,608 men made up the high-risk group. Within the 2 cohorts, the PARs for incidence and mortality of total carcinoma were 25% and 48% in women, and 33% and 44% in men, respectively. For individual cancers, the respective PARs in women and men were 82% and 78% for lung, 29% and 20% for colon and rectum, 30% and 29% for pancreas, and 36% and 44% for bladder. Similar estimates were obtained for mortality. The PARs were 4% and 12% for breast cancer incidence and mortality, and 21% for fatal prostate cancer. Substantially higher PARs were obtained when the low-risk group was compared with the US population. For example, the PARs in women and men were 41% and 63% for incidence of total carcinoma, and 60% and 59% for colorectal cancer, respectively.

From the results, it was concluded that a substantial cancer burden may be prevented through lifestyle modification. Primary prevention should remain a priority for cancer control.

Practice Pearls:
•89,571 women and 46,339 men from 2 cohorts were included in the study.
•Many cancer cases and even more deaths among U.S. white individuals might be prevented by quitting smoking, avoiding heavy alcohol consumption, maintaining a BMI between 18.5 and 27.5, and exercising at a moderate intensity for at least 150 minutes or at a vigorous intensity for at least 75 minutes every week.
•These compelling data together with the findings of the current study provide strong support for the argument that a large proportion of cancers are due to environmental factors and can be prevented by lifestyle modification.

Preventable Incidence and Mortality of Carcinoma Associated With Lifestyle Factors Among White Adults in the United States. May 19, 2016. doi:10.1001/jamaoncol.2016.0843.

Diabetes in Control June 11th, 2016

Carrot, dill and yoghurt salad

Aug 29, 2016Jul 6, 2016 kaitiscotlandLeave a comment

Carrot, Dill and Yoghurt Salad

Servings: 4
Time: 5 mins
Difficulty: easy
Print

1tbsp olive oil
220g grated carrot
3 tbsp Greek yoghurt
2 cloves of garlic, chopped
4 tbsp chopped dill
pinch of salt
40g toasted walnuts

Method

Warm oil and saute carrots until wilted.
Whisk 3 tbsp yoghurt, garlic, dill and salt.
Stir in carrots, scatter with walnuts and serve warm or cold.

Allow about 5g of carbs per serving.

Book review: Chimpanzee Politics by Frans De Waal

Aug 25, 2016Jul 12, 2016 kaitiscotlandLeave a comment

This book was first written in 1982 and has stayed in print since. It was updated for its 25^th Anniversary and this was the version that I read. What makes this book about a group of chimpanzees in a Dutch Zoo so popular with humans?

Chimpanzees are man’s closest ape relatives. We have only 2% difference in our DNA. Chimpanzees are about the same size as humans but are much stronger and have much more developed teeth, especially the adult males, who have canine teeth to rival a panther’s. Chimpanzees are much more acrobatic than humans and make excellent use of both hands and feet. One important difference is that they, and gorillas, cannot swim.

Like humans, they live in social groups that are hierarchically based and that are designed to maximise the well- being of the group and deter potential rivals for territory and food. They can be very aggressive indeed and hunt, kill and even eat other monkeys alive. They can mutilate and kill humans and other chimpanzees and can be highly unpredictable. For this reason humans at the zoo only had direct contact with infant and juvenile chimpanzees.

Interactions between the different individual adult males and females and juvenile chimpanzees were systematically recorded over a period of years. Hierarchy was determined by a development of subservience behaviour in the form of oral greetings and dominant behaviour in the form of displays and assaults. Making up, coalitions, friendly and dominance behaviour were common. In general male adults have the capacity to do more damage but they tend to reign in their aggression, whereas female adults are somewhat less powerful but tend to do a lot more damage in fights.

The leader of the pack, the alpha male, has more opportunity to mate with the females. Males lower in the hierarchy, may or may not be allowed to mate by the alpha male, but sex on the side can be arranged by the support and deceit of a helpful female.

Although the appearance, voice and behaviour patterns of each chimpanzee is individual, it is not usually possible for any male chimpanzee to be sure of the parentage of offspring in the group, since multiple matings often occur. The adult male chimpanzees will curry favour with the females by grooming them and tickling and playing with the babies. Sometimes however, like male lions, and humans, they will kill infant chimpanzees.

What I found fascinating about this book is the way that human behaviour mirrors chimpanzee behaviour so closely. We have better language and tool skills than chimpanzees, and our group activities are much more organised, but every day you will see behaviour that you clearly recognise as parallel to our hairier and not much less aggressive relations.

Can we humanise doctors’ working lives and all be safer?

Aug 22, 2016Jul 12, 2016 kaitiscotlandLeave a comment

NHS Hand-in: Department of Health — 38 Degrees members deliver a petition of over 410,000 names to the NHS. Their message: Save Our NHS

The Kings Fund, new GMC chairman and Canadian researchers hope so. So do many practising doctors. With the workload pressures, lack of extra resources and retention and recruitment crisis doing nothing is no longer an option. We are very strong on patient education on our site, but no matter how smart we can be about managing our diabetes and associated conditions, there are inevitably times that we will need to see a doctor and go into hospital for some procedure. The better the whole system is running the better it is for patients.

John Toussaint, CEO of the USA ThedaCare Center for Healthcare Value, says that freeing frontline clinicians to solve problems rather than controlling or blaming them could yield major improvements in three years. Organisations should radically change their leadership behaviour, make respect for people a guiding principle and ensure that productivity improvements did not lead to employee lay-offs.”

“Redesigning care to take wasteful steps out of processes improve quality and lower costs at the same time. Leaders must act with humility, take a sincere interest in what their staff are telling them, and build a culture of trust and systems geared to continuous improvement. Senior executives should scrap surplus strategic initiatives that are contributing to staff burn-out, focus on a few core goals, and give proper authority to clinical teams. He said that Western Sussex Hospitals had adopted elements of his system and achieved an outstanding rating from the Quality and Care Commission. He said that the hardest part was eliminating waste in non-clinical areas such as administration, IT, human resources and finance.”

When it comes to eliminating wasteful practice, the Quality and Outcomes framework is a good example. Payment by performance in British General Practice was a massively expensive experiment set up in 2004. In Scotland it has just been abandoned. Almost all GPs hit the desired targets for chronic disease health care identification and monitoring. 25% of GP income was tied to the targets, often of dubious value. Many GPs left or retired and it is believed that the strain of delivering QOF has put many young doctors off being GPs. A study in the Lancet however showed all this was for nothing. There was no benefit to total mortality for any of the diseases covered compared to usual care.

Terrence Stephenson is the current chairman of the General Medical Council in the UK. He delivered a lecture to the Royal Society of Medicine in which he expressed the desire that the GMC shake off the “policeman” image that they have.

“For most doctors, the GMC is known for tackling bad practice and striking doctors off the register. The GMC get 10,000 complaints a year, most of which come from the general public. Making complaints is free, easy and you can even do it online. Unfortunately it can be used in highly inappropriate ways. For instance someone complained that trees from a practice’s garden were blocking their sunlight. Of these complaints 250 are directed to a tribunal and of these 55 doctors were struck off the register.”

“ I think we need reforms to this procedure. Many complaints are erroneous. Many could be dealt with locally. Many patients would be better satisfied if they went through local complaints procedures or the ombudsman. It is my ambition to make the GMC more focussed on patient safety. The sad truth is that medicine is a high risk profession. It is safety critical industry and people are harmed by healthcare. In any human business there will be human error that can never be eradicated but I think it behoves us to try and fix it”.

When it comes to human errors we all know that lack of sleep, overwork, interruptions, boredom, unfamiliarity with the work can all contribute. Being hungry and thirsty also impair us.

Canadian researchers suggest regular meal breaks for doctors. Many work long shifts with no guaranteed breaks. Healthy food should be available. (Not just sandwiches and crisps I hope!). Food outlets should be open 24 hours to accommodate shift workers. Staff should be able to store and eat food near to where they actually work. They also suggest that professional bodies increase awareness of doctors’ nutrition and their well-being and promote self-care for doctors.

Based on several articles in the BMJ 4 June 16

Ending blame culture would improve NHS care in three years by Matthew Limb freelance journalist

QOF and mortality Richard Lehman Lancet 2016 doi:10.1016/SO140-6736(16)00276-2

Fitness to practice process must change by Abi Rimmer

Five ways to help doctors eat healthily at work doi:10.1136/postgradmedj-2016-134131

Jovina Cooks Italian: Orange Roasted Chicken

Aug 18, 2016Jul 29, 2016 kaitiscotland1 Comment

Orange Roasted Chicken

Servings: 8
Time: 2hr 30mins
Difficulty: easy
Print

Ingredients

Zest of 5 bergamot oranges (or ordinary oranges if you can’t get them)
1 cup bergamot orange juice
3 finely minced garlic cloves
2 tablespoons finely chopped herb mixture (rosemary, sage, thyme, oregano)
¼ cup olive oil
1 (3-pound) chicken, cut into 8 pieces, bone-in, skin-on
¼ cup butter, softened and room temperature
½ teaspoon paprika
1 bergamot orange, cut into thick slices for garnish
Sea salt and freshly ground black pepper
Herb sprigs for garnish

Directions

In a mixing bowl, combine half of the orange zest with the orange juice, garlic, herbs and olive oil. (Set aside the remaining zest for later.)
Stir to combine and pour into a very large zip-lock bag. Add the chicken pieces and move them around to ensure they’re all coated with the marinade.
Seal the bag and place into a bowl (in case it leaks) and then into the refrigerator to marinate for at least 3 hours and up to overnight.
Preheat the oven to 375 degrees F.
In a mixing bowl, combine the softened butter with the paprika and the remaining orange zest.
Remove the chicken pieces from the bag and place them in a 9 X 13 X 2-inch baking dish. (Set aside the marinade in the bag.)
Season both sides of the chicken with salt and pepper and then using your hands rub the butter mixture under the skin of each chicken piece and on top of the skin.
Pour the marinade over the chicken and add the orange slices. Place the baking dish in the oven and roast the chicken until it’s cooked through, about 45 minutes.
Baste the chicken several times during cooking.
Let the chicken rest for at least 10 minutes before serving. Garnish with fresh herbs, if desired.

From Jovina Cooks Italian.

Insulin Before Exercise May Be Needed to Lower Morning Highs

Aug 15, 2016Jul 12, 2016 kaitiscotland5 Comments

Diabetes in Control has a lessons learned section for health professionals. Although we commonly think of exercise that will lower our blood sugars some insulin users find the opposite occurs. This is the case report.

A man with type 1 diabetes started an exercise program to help him manage his early morning highs. He exercised every evening, at which time his glucose levels would drop during and after exercise. Thinking that exercise would lower his early morning highs, he did not take his insulin before exercise. He was surprised to see his glucose would go up after exercise rather than go down….

He discussed this with his endocrinologist who recommended he take a very small amount of fast- or rapid-acting insulin before exercise. His glucose levels did well. He was surprised to see his levels did not get low, nor were they high after exercise anymore. This became his regular regime.

Lesson Learned:
•Even though exercise makes an individual more insulin sensitive, one still needs insulin for muscles to use glucose. Without enough insulin, glucose levels can rise.
•Individuals can and usually do have different insulin needs throughout the day.
•To lower post-exercise highs, start low and go slow to learn the amount of insulin your patient needs. Some need only one unit.
•Check before, during, and after exercise, or better yet, use CGM and track trends.

Anonymous

From Diabetes in Control 27 April 2015

Statin therapy associated with increased insulin resistance and type two diabetes

Aug 12, 2016Jul 12, 2016 kaitiscotland1 Comment

According to a new study, statin therapy may increase the risk of type 2 diabetes by decreasing insulin sensitivity and secretion. Overall, there was a 46% increase in the risk of type two diabetes.

Statins are considered to be safe and well-tolerated medications commonly used for the prevention of cardiovascular disease (CVD) events in individuals with and without diabetes. However, recent studies showed that statins might increase the risk of type 2 diabetes. The goals of this study were to analyze the effects of statins on the risk of type 2 diabetes and investigate the mechanisms of this process based on insulin resistance and insulin secretion.

This study was a 6-year follow-up of the population-based Metabolic Syndrome in Men (METSIM) performed in 2005 to 2010. A total of 8,749 non-diabetic men aged 45 to 73 years old was randomly selected from a population in Kuopoi, Eastern Finland. An OGTT (75 g of glucose, glucose and insulin measurements at 0, 30, and 120 min) was performed, then glucose tolerance was classified based on the American Diabetes Association criteria. Exclusion criteria included patients with previously diagnosed type 1 diabetes, newly or previously diagnosed type 2 diabetes, or those without an OGTT at baseline. A total of 625 of the 8,749 individuals enrolled were diagnosed with type 2 diabetes during a 5.9 year follow-up study. Out of 8,749 individuals, 2,142 patients were on statin medication at baseline. Measured variables included height, weight, BMI, waist circumference, smoking status, family history of diabetes, physical activity, alcohol intake, the use of beta-blockers and diuretics at baseline, and history of non-fatal myocardial infarction or stroke. Laboratory measurements included plasma glucose, HbA1c, plasma insulin concentrations, LDL, HDL, and total triacylglycerols. T-test and chi-squared tests were used for statistical analyses.

The results showed that individuals on statin treatment had a 46% increased risk of type 2 diabetes (adjusted HR 1.46 [95% CI 1.22, 1.74]). The increased risk is dose-dependent for atorvastatin and simvastatin (simvastatin HR 1.44 [95% CI 1.23, 1.68] and 1.28 [95% CI 1.01, 1.62] for high and low dose, respectively, and atorvastatin HR 1.37 [95% CI 1.14, 1.65]). Study also showed that statin treatment increased glucose AUC, 2 h glucose (2hPG), and fasting plasma glucose at follow-up. Insulin sensitivity and insulin secretion were decreased by 24% and 12%, respectively, in statin group compared to non-statin group (p<0.01). The decrease in insulin sensitivity and insulin secretion were dose dependent for atorvastatin and simvastatin.

In conclusion, after adjustment for confounding factors, statin treatment was shown to increase the risk of type 2 diabetes due to decreases in insulin sensitivity and insulin secretion.

Practice Pearls:
•Statin therapy was associated with a 46% increase in the risk of type 2 diabetes.
•Insulin sensitivity and insulin secretion were decreased by 24% and 12%, respectively in statin group compared to non-statin group.
•For atorvastatin and simvastatin, the risk of type 2 diabetes and the decreased in insulin sensitivity and insulin secretion were dose-dependent.

Cederberg et al. “Increased risk of diabetes with statin treatment is associated with impaired insulin sensitivity and insulin secretion: a 6 year follow-up study of the METSIM cohort.” Diabetologia. May 2015;58(5):1109-1117.

From Diabetes in Control 24 April 2015