Writing down your thoughts can boost your mood

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Adapted from Human Givens No 1 2013 Brinol P et al. Treating thoughts as material objects can increase or decrease their impact on evaluation. Psychological Science 24.1, 41-7. 2013.

Writing down negative thoughts, crumpling them up, and throwing them away, as often advocated by therapists, really does reduce negative thinking. Conversely, writing positive thoughts down, and keeping them safe in a purse or pocket helps you feel better.

Teenage School students in Spain were asked to write down either positive or negative thoughts about their bodies and then Mediterranean diet and they were then evaluated on how much they became influenced by their lists later on.

What they found was that people who threw the list in the trash right away were not influenced, those who kept the list in their desk were somewhat influenced, but that those who kept the list more personally in a pocket or purse were most influenced.

To see if the effect worked with word lists via a computer, the experiment was repeated. The thoughts were put into storage or the trash list. Repeating the experiment but simply asking the students to imagine putting the list in a particular location without physically doing anything was also done.

Professor Richard Petty, a co-author of the paper from Ohio University said, ” The more convinced the person is that negative thoughts are really gone, the better. Just imagining that you throw them away doesn’t seem to work”.

So, to get over a difficult event, write it down, and then bin it and be physical.

If you want to boost your mood, write positive facts or feelings and keep it close and personal.

Nick Norwitz:Ketogenic diets may be used to treat mental illness in the future

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Adapted from Ketogenic diet as a metabolic treatment for mental illness by Nicholas Norwitz et al

Wolters Kluwer Health Inc. http://www.co-endocrinology.com 2020

Ketogenic diets have been used to treat drug resistant epilepsy in children for over one hundred years.

Now they are being used for other neurological conditions such as schizophrenia, depression, bipolar disorder and binge eating disorder.

There is strong evidence that common biological pathologies underlie these conditions such as abnormal glucose metabolism, neurotransmitter imbalances, oxidative stress and inflammation. These factors are all improved with a ketogenic diet.

Controlled clinical trials have shown improvement in: Obesity, Type Two Diabetes, Multiple Sclerosis, Epilepsy, Alzheimer’s disease and Autistic Spectrum Disorder.

Uncontrolled clinical trials have shown improvement in: Parkinson’s disease and Schizophrenia.

Case series and animal models have shown improvement in: Cardiovascular Disease, Binge eating disorder, Major Depressive disorder, Bipolar disorder and ADHD.

It is estimated that people who have mental illness live around 7 to 10 years less than those who do not have a mental illness. Sometimes this is due to suicide, but more often it is due to concurrent diabetes, heart disease, respiratory disease, infectious disease and cancer. All of these conditions are raised in people with mental illness. Sometimes this is due to poor health behaviours such as smoking or other lifestyle issues, and drug side effects can also cause problems. But even in people of a healthy weight and who are not on drugs, if they have mental illness, they are also more likely to have physical illness. Could switching the body and brain away from glucose use towards fat and ketone use improve matters?

Cerebral glucose hypometabolism and insulin resistance are features of Alzheimer’s disease, Parkinson’s disease, Schizophrenia, and Epilepsy. In one recent Cochrane review of epilepsy, as many as 55% of patients had complete remission of their fits on a ketogenic diet.

GABA/glutamate imbalance is a feature of Epilepsy and Schizophrenia. Oxidative stress is a feature of Schizophrenia, Bipolar disorder and Major Depressive Disorder. Oxidative stress and inflammation are mutually reinforcing processes. Major Depressive Disorder, Schizophrenia have these issues.

The Virta Health Group has demonstrated that a ketogenic diet is a well tolerated and effective strategy for treating type two diabetes. It reversed the condition in 54% of patients compared to 5% who received standard care. Alzheimer’s patients also improved on a ketogenic diet and also benefitted from medium chain triglyceride supplementation. (MCTs). Parkinson’s disease, Huntington’s disease and Multiple Sclerosis patients also showed improvement in studies. About 50 to 80% of patients with Alzheimer’s disease have cross over symptoms with schizophrenia, Bipolar disorder and major depressive disorder. These conditions all share common metabolic abnormalities.

It is thought that the ketogenic diet affects the gut microbiome and gut issues are thought to influence Autistic Spectrum Disorder. Two clinical trials reported sometimes complete symptom remission in patients with Childhood Autism when treated with a ketogenic diet.

Some case studies involve psychiatric patients who embarked on ketogenic diets for weight loss and gut problems, only to find a massive improvement in their mental conditions as well. Dr Christopher Palmer reported about an elderly woman with over 50 years of schizophrenia who was able to stop all her antipsychotic medication and has been symptom free for over 12 years. Another middle aged woman who had schizophenia and depression went into complete remission and was able to get her degree and a full time job in the last four years. Both remain unmedicated and on their ketogenic diets.

Results with Binge eating disorder have also been impressive. These patients are usually on 20-30g of carbohydrate a day.

Yoga and dance give pain relief for functional abdominal pain in girls

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Abdominal pain in childhood is associated with increased risk for persistent long term pain and severe mental illness in adulthood. Therefore, it is good to see that a simple intervention of involvement in dance and yoga were considerably more effective in dealing with functional pain than in girls who received standard care.

This was a prospective, multicentre, randomised controlled trial. 121 girls aged between 9 and 13 with functional abdominal pain syndrome or irritable bowel syndrome had standard care or participated in dance and yoga intervention twice a week for 8 months. 55% of the intervention group continued for the whole 8 months of the study.

The dance group were more likely to report a decrease in the maximal abdominal pain at 4 months and 8 months. At 8 months 46% of the dance group reported less pain compared to 17% in the control group.

Hogstrom et al. Dance and yoga reduced functional abdominal pain in young girls. A randomised controlled trial. Eur J Pain. 2021 Sept 16.

Working is good for women’s brains

Adapted from BMJ 21 Nov 2020

Being employed seems to reduce the onset of dementia in women later on in life.

In the USA, 6 thousand women took part in the Health and Retirement study. Rates of memory decline were around 50% faster in those women who did not work for pay in the years after having children. Regardless of marital status and whether they had children, women who worked for pay in early adulthood and midlife showed slower rates of later life memory decline.

My comment: I wonder if the 80 years full time equivalent that I’ve racked up for the NHS will stand me in good stead then?

Once you are old, both men and women’s rates of memory decline from Alzheimer’s greatly accelerates if either experience the death of their spouse.

The Harvard Ageing Brain study did PET scans of participants’ brains at recruitment. They then had annual cognitive assessments. Those who had higher amyloid in the brain to star with deteriorated faster whether they were married or not, but the steepest drop occurred in those whose who were widowed.

Blood pressure difference between arms can be a risk factor for cognitive decline…as well as other things.

From Systolic inter-arm blood pressure difference and cognitive decline in older people, a cohort study. Christopher E Clark. BJGP July 2020

 

A prospective study was done in 1,113 Italians whose average age was 66.4 years. Even a difference of only 5 degrees between the arms was associated with a greater level of cognitive decline.

My comment: In UK GP practices, only one arm is used to check the blood pressure. In my case, it was the arm that was nearest to the desk. Perhaps we should check both ? Inter-arm BP differences are both associated with cardiovascular disease, and this in turn affects dementia. Then of course, is the question, what can you do about it? For a further discussion of the subject here is Pharmacist Antonio Bess from Diabetes in Control.

Cognitive Decline: Just Life, or a Preventable Disease?
Feb 22, 2020

Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

Cognitive decline is associated with many diseases and medications, but the exact mechanisms are not clearly understood.
Diabetes, obesity, and declining cognitive function are all associated with increased prevalence with increasing age.

Diabetes is a known risk factor for eye, kidney, neurological and cardiovascular diseases, but its effect on declining cognitive function has been in question. Previous studies have found associations between patients who have diabetes and poor glycemic control and significantly faster cognitive decline. Other studies have demonstrated a pattern in which diabetes, high blood pressure, and high body mass index in midlife predict dementia in late life.

In this prospective study, individuals were followed for up to ten years to find associations between indices in diabetes, insulin resistance, obesity, inflammation, and blood pressure with cognitive decline. The indices of interest were measured separately among those with and without central obesity.
The Monongahela‐Youghiogheny Healthy Aging Team is a population‐based cohort of participants recruited randomly from 2006 to 2008, who were 65 and older, and were from a group of small towns in southwestern Pennsylvania. The study is focused on the epidemiology of cognitive decline and dementia in an area that still has not recovered economically from the collapse of the steel industry in the 1970s.

Participants were analyzed at study entry, and annual follow up. To measure cognitive function, participants were given a panel of neuropsychological tests tapping the domains of attention/processing speed, executive function, memory, language, and visuospatial function. At study entry and annually, BP, BMI, waist‐hip ratio, and depressive symptoms  were measured.
Key variables at the time of blood draw, including age, sex, race (white vs. nonwhite), education (high school [HS] or less vs. more than HS), APOE*4 allele carrier status, mCES‐D score, BMI, WHR, systolic BP (SBP), and the following laboratory assay variables: CRP, glucose, HbA1c, insulin, HOMA‐IR, resistin, adiponectin, and GLP‐1 were all reviewed to identify predictors of cognitive decline.
Among 1982 participants who were recruited and underwent full assessment at baseline from 2006 to 2008, only 478 individuals were able to provide fasting blood samples. Of this group of individuals, the median age was 82 years; 66.7% were women; 96.7% were white, and 49.0% had more than HS education.

Compared to the 1504 original participants without fasting blood data, at baseline, these 478 were significantly younger (74.6 vs. 78.6 years; P < .001); more likely to be women (66.7% vs. 59.2%; P = .004); more likely to be of European descent (96.7% vs. 94.1%; P < .001); more likely to have at least HS education (49.0% vs. 38.6%; P < .001); but about equally likely to be APOE*4 carriers (19.3% vs. 21.5%; P = .350).
In unadjusted analysis in the sample as a whole, faster cognitive decline was associated with greater age, less education, APOE*4 carriage, higher depression symptoms (mCES‐D score), and higher adiponectin level. HbA1c was significantly associated with cognitive decline.

After stratifying by the median waist-hip ratio, HbA1c remained related to cognitive decline in those with higher waist-hip ratios. Faster cognitive decline was associated, in lower waist-hip ratio participants younger than 87 years, with adiponectin of 11 or greater; and in higher waist-hip ratio participants younger than 88 years, with HbA1c of 6.2% or greater. Higher adiponectin levels predicted a steeper cognitive decline in the lower waist-hip ratio group.
Abdominal obesity plays a crucial role in cognitive decline in those with diabetes. The microvascular disease may play a more significant role than macrovascular disease. Midlife obesity contributes to cognitive decline but there was no midlife data in this study. Future studies should include a large minority, midlife population. Adiponectin levels need to be carefully assessed as well.

Practice Pearls:
In individuals younger than 88 years old, central obesity can lead to faster cognitive declines.
Obesity, diabetes, and aging contribute to cognitive decline, so it’s hard to distinguish the most significant risk.
Adiponectin may be a novel independent risk factor for cognitive decline and should be reviewed.

Ganguli, Mary, et al. “Aging, Diabetes, Obesity, and Cognitive Decline: A Population‐Based Study.” Journal of the American Geriatrics Society, John Wiley & Sons, Ltd, Feb. 2020, p. jgs.16321, doi:10.1111/jgs.16321.
Ganguli, Mary, et al. Aging, Diabetes, Obesity, and Cognitive Decline: A Population-Based Study. 2020, pp. 1–8, doi:10.1111/jgs.16321.
Tuligenga, Richard H., et al. “Midlife Type 2 Diabetes and Poor Glycaemic Control as Risk Factors for Cognitive Decline in Early Old Age: A Post-Hoc Analysis of the Whitehall II Cohort Study.” The Lancet Diabetes and Endocrinology, vol. 2, no. 3, Elsevier Limited, Mar. 2014, pp. 228–35, doi:10.1016/S2213-8587(13)70192-X.
Cukierman, T., et al. “Cognitive Decline and Dementia in Diabetes – Systematic Overview of Prospective Observational Studies.” Diabetologia, vol. 48, no. 12, Springer, 8 Dec. 2005, pp. 2460–69, doi:10.1007/s00125-005-0023-4.

Antonio Bess, Florida Agricultural and Mechanical University College of Pharmacy

It’s not usual to have perfect mental health

A study of children from birth until they were well into middle age showed that 86% of them met the criteria for a psychiatric disorder at least once during nine assessments undertaken by a psychiatrist from the age of 11 to 45.

The study was undertaken in the South island of New Zealand. Most of them had multiple diagnoses.

The conclusion was that sustained good mental health is the exception rather than the rule and that people often manifest their mental health difficulties in different ways over their life span.

JAMA Netw Open doi:10.1001/jamanetworkopen.20203221.

Stress may damage your immune response long term

Adapted from: Stress related disorders and physical health.  Song H. et al. BMJ 26 Oct 19.

This Swedish study of almost 145,000 brothers and sisters showed that any sort of anxiety or stress disorder was associated with an increased risk of life threatening infections, even when familial background, physical and psychiatric problems were adjusted for.

The study went on between 1987 and 2013. The stresses included post traumatic stress disorder, acute stress reaction, adjustment disorder and others. The patients were matched with healthy siblings when possible or matched comparative children from the general population.  They then looked for diagnosis of severe infection in the coming years such as sepsis, endocarditis, meningitis and other infections.

Severe infection rates per 1,000 person years were 2.9 for the stressed person, 1.7 for the healthy sibling, and 1.3 for the matched person in the general population.

They found that the effects were worse the earlier the age the diagnosis of the stress occurred.

Treatment with serotonin re-uptake inhibitors for PTSD seemed to reduce the negative effects on the immune system when given within a year of the stress diagnosis.

This research builds on information that PTSD produces more gastrointestinal, skin, musculoskeletal, neurological, heart and lung disorders.  Cardiac mortality has been found to be raised 27% and autoimmune disorder by 46%.

Why this happens could be due to the interplay between biological, psychological and social factors. Increased inflammatory response is considered by Song and colleagues to be a likely mechanism. Increased levels of interleukin 6, interleukin 1 beta, tumour necrosis factor alpha and interferon gamma have been found in those with PTSD.

PTSD has a heritability factor of 5-20% which is similar to what is found in families with depression.  It is likely to be polygenic.

Talking based therapies are generally even better for PTSD than drugs, so earlier intervention may have long term benefits not just on mental health, but physical health as well.

BMJ 2019;367:16036

Higher blood pressure is linked to LESS cognitive decline

From Streit S et al. Ann Fam Med 1 March 2019 and reported by Sarfaroj Khan UK Clinical Digest 13 March 2019

In my GP career treatment of blood pressure for the general population has become more intensive as time has gone on. This hasn’t always resulted in better long term outcomes overall. Indeed, the target systolic blood pressure, the upper measurement, has been moved from 130 to 140 in the last few years because of this.

A Dutch study of over a thousand patients over the age of 75 showed that those with a systolic blood pressure under 130 showed more cognitive decline than those with a blood pressure over 150 when they had mental functioning tests a year later.

Those with higher blood pressures had no loss of daily functioning or quality of life.

As aggressive blood pressure control in those with diabetes is standard treatment, it is worth knowing this. Perhaps further studies in this subgroup of patients would be worth doing. I have seen reports of impaired kidney function when blood pressure levels are “optimal” but low too.

Another study regarding blood pressure management reported in the British Journal of Sports Medicine indicates that blood pressure reduction of almost 9mm Hg in hypertensive patients when regular structured exercise is undertaken. This is of a degree similar to most anti-hypertensive medications. (Reported in BMJ 5 Jan 2019)

 

 

Hypoglycaemia: the neglected complication

Adapted from Hypoglycaemia: the neglected complication by Sanay Kalra et al.

Indian J Endocrinol Metab. 2013 Sep-Oct; 17(5): 819-834

Hypoglycaemia is an important complication of glucose lowering therapy in patients with diabetes mellitus. Attempts made at intensive glycaemic control invariably increases the risk of hypoglycaemia. A six fold increase in deaths due to diabetes has been found in patients with severe hypoglycaemia compared to those not experiencing severe hypoglycaemia.

Repeated episodes can lead to hypoglycaemia unawareness. Complications  of hypoglycaemia include stroke, heart attacks, cognitive dysfunction, retinal cell death and loss of vision. Apart from this there are the effects on quality of life regarding sleep, driving, employment, exercise and travel.

To maintain good glycaemic control, minimize the risk of hypoglycaemia and thereby prevent complications, there are steps that need to be taken: recognise risk factors for hypoglycaemia, use appropriate self monitoring of blood sugar, select treatment regimens that have little or no risk of incurring hypoglycaemia and teach health care professionals and patients how to avoid hypoglycaemia.

Although the DCCT showed that complications were reduced when blood sugars were brought under a HbA1C of 7%, other trials have noted a three fold risk of hypoglycaemia when the level is reduced under 6.5%. This tends to negate any improvements in long term complications.

Insulin users are most at risk. Those who have had diabetes for more than 15 years are particularly at risk. The DARTS study showed that the risk of severe hypoglycaemia was 7.1% for type one patients, 7.3% for type two patients and 0.8% for type twos on sulphonylureas. This causes increased cost for their healthcare as hospitalisation for around a week is needed in the average case.

The majority of hypos are due to medications but there are other potential causes such as: pancreatic or islet cell tumours, dietary toxins, alcohol, stress, infections, sepsis, starvation and excessive exercise.

In diabetics not eating enough food was the most common cause. Others were physical exercise, insulin miscalculation, stress, overtreating a high blood sugar, and impaired glycaemic awareness.

Nocturnal hypoglycaemia is seen in half of diabetic children, particularly under the age of 7. Dead in bed syndrome causes 5-6% of all deaths in type one youngsters.  Contributory factors are increased exercise that day or delayed meals.

In type two patients additional causative factors are alcohol ingestion and liver disease and duration of insulin over ten years. As in type ones there tends to be more hypoglycaemic unawareness as the person ages. In type twos  there is a 9 fold increase in deaths in those with hypoglycaemic unawareness.

Severe hypos in elderly patients increase the risk of dementia, functional brain failure and cerebellar ataxia. There are clear signs of neuronal death in specific brain areas at post mortem in these patients and a history of fits make these more extensive.

Hypos in elderly patients promote cardiac ischaemia. Arrhythmias are more likely due to catecholamine release during hypos. Prolonged QT intervals lead to increased heart rate, fibrillation and sudden cardiac death.  Inflammatory cytokines are released during hypos, abnormalities of platelet function and the fibrinolytic system occur.

Hypos can cause double vision, blurred vision and dimness of vision.  Blindness can occur due to retinal cell death.

Recurrent hypos make people feel powerless, anxious and depressed. Acute hypos cause mood swings, irritability, stubbornness and depression.  Quality of life scores are worse in patients with recurrent hypos.

Driving ability is affected by hypos. The affected driver can inadvertently cross lanes and speed and generally drive worse.

Hypos at night may be recognised by sleep disturbance, morning headaches, chronic fatigue and mood changes. In young children fits and bed wetting may occur.

Hypos at work can be awkward, embarrassing and frightening. Hypos are particularly dangerous for those who work at heights, underwater, on railway tracks, oil rigs, coal mines, handling hot metals or heavy machines.

Expert medical advice and planned action counselling can help workers. So can self blood glucose testing, healthy food options in canteens, flexible meal times, arrangements to carry and use emergency glucose/sugar, storage and disposal sites for medications and sharps, and time off for medical appointments. Work time and productivity due to hypos can be reduced and nocturnal hypos can also have a knock on effect the next day.

Hypos in children tend to be increased in summer months when they are more active. In adults, intense prolonged exercise following an episode of recent severe hypoglycaemia can damage skeletal muscle and the liver and can cause severe neurological symptoms.

Travelling long distances, particularly over times zones can cause insomnia, tiredness, stress, reduced appetite, nocturia,  gastric disturbance, muscle aching and headaches. Psychological symptoms include low mood, irritability, apathy, malaise, poor concentration. These deficits in both physical and mental performance can profoundly affect decision making.

The fear of hypos can affect patients more profoundly than the fear of long term complications.  Withholding of insulin can occur. Sometimes patients refuse to start it when they need it and sometimes they miss out their doses.

About 30% of type one patients are affected by hypoglycaemia unawareness and under 10% of type two patients are thus affected. Duration of insulin use is the main common factor.

Educating patients about how to detect, treat and prevent hypoglycaemia must be understandable to the patient and their family.

In 2013 the ADA recommended that insulin users test their blood sugars 6-8 times a day.

Basal insulin needs to be matched to the patients needs. If hypos persist, particularly overnight, switching to pump therapy may help.

Newer diabetic medications, which do not cause low blood sugars such as the gliptans and gliflozins, may be preferable in type two patients who have multiple co-morbidities, are elderly,  who live alone, are at high risk of falls, and who have hypoglycaemia unawareness or who otherwise could not effectively deal with a hypo.

 

 

 

Bring back the 50s ?: Mothers in full time work are significantly stressed

Being a working mother doesn’t just feel stressful, it alters your physiology.

Researchers at the universities of Manchester and Essex studied 6025 people. They collected information about their working and home lives. Hormonal levels and blood pressure were checked too.

When 11 biomarkers of stress were tested, these were 40% higher in women who worked full time and were raising two children at the same time. One child raised the levels by 18%.  Part time workers, job sharers and those with flexible working arrangements were fewer hours were worked had less stress.  Flexible working or remote working with no reduction in hours did not lower stress levels.

The authors said, ” Work-family conflict is associated with increased psychological strain, with higher levels of stress and lower levels of well being. Parents of young children are at particular risk of family-work conflict.

http://www.manchester.ac.uk/discover/news/working-mothers-up-to-40-more-stressed/