Heartburn is miserable. That aching, acidy feeling that you have in the middle of your chest or throat area is common to more than 60 million Americans at least once per month and 15 million adults daily. Heartburn, also known as gastroesophageal reflux disease (GERD) is a digestive disorder affecting the stomach and the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. This condition refers to the reflux, or return of the stomach’s contents back up into the esophagus.

In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and stomach acid juices from flowing back into the esophagus. You may assume the cause of GERD is too much acid. But the truth is more complicated. As people age, the digestive tract muscles become weaker and stomach acid levels naturally decrease. This means that heartburn may actually be caused by too little acid, known as hypochlorhydria, or by other issues related to muscle weakness. A certain amount of stomach acid is needed to help close the LES, so when stomach acids are low, the LES cannot fully close.

Other factors that contribute to GERD include being overweight, taking medication that weakens the LES (calcium blockers and certain hormones), eating when stressed or rushed and eating too late at night. Heartburn can also be a symptom of celiac disease or other food allergies.

Some doctors believe a hiatal hernia may weaken the LES and increase the risk for GERD. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (a muscle separating the abdomen from the chest). The opening in the diaphragm supports the lower end of the esophagus. Having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus. Many people with a hiatal hernia may not have problems. Most people do not require treatment unless the hernia is severe enough to raise the risk of strangulation (twisting that cuts off the blood supply) or heartburn symptoms are severe.

So what can you do?
1. Eat smaller frequent meals. Do not overeat. Stop eating when you are no longer hungry vs eating until you “feel” full.
2. Chew your food. When chewing your food, saliva has its own essential digestive enzymes that help break down your food and improve the digestive process.
3. Don’t eat when rushed, and eat your last meal/snack at least 2-3 hours before bedtime.
4. Avoid trigger foods: chocolate, peppermint, coffee, alcohol, tomatoes, citrus foods, fatty foods and fried foods.
5. Supplements can be helpful: Dr. Leo Galland MD in NYC recommends a combination of calcium citrate (chewable or drinking a calcium citrate drink) after each meal and Melatonin at bedtime to help strengthen the LES valve.
6. Supplementing with Betain hydrochloric acid (HCL) right before each meal may help restore stomach acid levels. Other options are to take 1 dropper of chinese bitters in a tincture or 1 Tbsp of organic apple cider vinegar in 1 cup of warm water before meals.
7. Stop Smoking

Talk to your practitioner before adding any supplements. Ask about any underlying issues that might be causing your heartburn and what treatments might work best for you. The treatment might be a change in the medications you are taking.

References: Galland, L. “Heartburn? why low acid might be the problem”. mymagazine.us, p 25-26.
Khatri, M. Webmd.com. “Gastroesophageal Reflux disease (GERD). September 19, 2019.

We may have discussed that our microbiome and gut health influences mood and behavior, but didn’t really know how until now. More research has emerged giving us a deeper look at the microbiomes responses to stress.

Studies have been done on mice identifying differences in cell wiring, brain activity and gene expression. This is a fascinating article identifying certain compounds created by microbes in the gut that are involved in nervous system signaling. The microbiome may produce certain substances in abundance that make their way into the brain.

We know that the intestinal microbiome is altered in those with brain conditions. But what we don’t know is whether the differences in the microbiome give rise to neurological problems or does the neurological condition change the microbiome. There is also disagreement on the consequences of a healthy and unhealthy microbiome and what types of bacteria provide either risk or resilience to stress-related disorders. Maybe it’s not particular microbes as much as it is the diversity of the microbiome.

The study of microbial effects on the nervous system is still quite young. Animal studies may show some correlation between the microbiome and the nervous system but they don’t point to any treatments in humans. Humans process emotion, physical sensation and cognition in the brain differently than animals. In humans vs animals, our environments affect our nervous system by way of the microbiome and then there are diet-driven differences as well.

Interventions targeting the microbiome might be the most effective in infancy and childhood. The microbiome is most influential in infancy when the microbiome is still developing and early programming takes place in the brain. The hope someday is to identify microbial substances that help predict who is most vulnerable to disorders like post-traumatic stress disorder.

Human microbiomes continue to evolve as more people have come to live in cities and brain disorders have become more prevalent. The complexity of microbes inhabiting each of us has evolved with our species and it’s vital that we understand how they impact us physically, mentally and emotionally.

https://www.quantamagazine.org/how-microbiomes-affect-fear-20191204/

There have been some amazing health breakthroughs this year from prostate cancer treatment drugs, artificial intelligence in healthcare to a promising Alzheimer’s drug. Some of these innovations will change healthcare and enhance healing in the upcoming year. Here are the top 10 health breakthroughs of 2019:

10. Pharmacogenetic Testing– Chronic pain is the leading cause of opioid prescriptions. The opioid crisis has been declared a public health emergency and even though alternative therapies exist, none have reduced the incidence of this crisis. Now there is pharmacogenomic testing which uses a patient’s genetic makeup to predict how certain medications get metabolized. This testing can be used to avoid adverse reactions and eliminate ineffective prescriptions.

9. Artificial Intelligence (AI)– AI is allowing physicians to make smarter decisions by improving the ease and accuracy of viewing patient scans. For example, machine learning algorithms are able to highlight problem areas on images which can screen patients that need further testing and make sense of the mountain of data that doctors need to sift through.

8. New Drug Treatment for Prostate Cancer– Boston’s Dana-Farber Cancer Institute was leading a trial in which the drug Enzalutamide- an androgen-receptor inhibitor that stops the growth of cancer cells- was being used along with testosterone suppression to treat metastasized prostate cancer. Results have been very effective and this drug has been FDA-approved for other uses. It is under review to make it more widely available for metastasized prostate cancer patients.

7. New Alzheimer’s Drug– A new drug to treat Alzheimer’s disease called Aducanuab, is currently seeking FDA-approval. After 18 months of using the drug, participants showed lowered cognitive decline (15-27%) on memory and cognitive tests compared to a placebo.

6. Crispr-Gene Editing Tool– This gene editing tool allows scientists to modify DNA and genes. A patient has already been treated successfully for sickle cell disease. and clinical trials are underway to treat cancers such as non-Hodgkin’s lymphoma.

5. A possible Cure For H.I.V– Two people have been cured from H.I.V., the virus that causes AIDS. It resulted from bone marrow transplants given to the infected patients to treat cancer, not H.I.V. Rearming the body’s immune cells may work in the future.

4. Psychedelic Drugs to treat Mental Health Problems– Johns Hopkins Medicine announced the opening of the Center for Psychedelic and Consciousness Research to study compounds like psilocybin (magic mushrooms) and LSD. One study found that psilocybin can be more effective in helping people quit smoking compared to those using a nicotine patch.

3. Patient Specific Products with 3D Printing Medical devices can be matched to the exact specifications of a patient. It minimizes the risk of complications, increases comfort and improves performance outcomes. Most common devices include external prosthetics, cranial/orthopedic implants, and customized airway stents for diseases narrowing the airway.

2. Visor for prehospital Stroke Diagnosis– A new diagnostic tool called the hemorrhage scanning visor can detect bleeding in the brain much faster if someone is having a hemorrhagic stroke. Rapid diagnosis is essential for treatment as uncontrolled bleeding can lead to swelling and damage to the brain.

1. Peanut Allergy Treatment A new study out of Stanford University showed that after 1 injection of the antibody, etokimob, people with severe peanut allergies were able to eat peanut protein after 2 weeks. This antibody is being studied to treat other immune issues such as asthma and eczema.

Wishing you a year of love, good health, personal growth and success. Happy New Year!

The age at menopause is an important risk factor for cardiovascular disease. Pooled data from >300,000 participants without prior hysterectomy in 15 observational studies were studied. Premature menopause was defined as the absence of menstruation for 12 months before the age of 40; early menopause between the ages of 40-44; and relatively early defined between the ages of 45-49. The reference group was ages 50-51.

Results indicated that compared to the reference group, premature and early menopause were important risk factors for cardiovascular disease. Compared with women who had menopause at age 50-51, women with premature and early menopause had a substantial increase risk of a non-fatal cardiovascular event before the age of 60 years, but not after age 70 years. Women who reached menopause after the age of 52 had slightly decreased risk of coronary heart disease and stroke.

All women in their 40’s need to be assessed for cardiovascular risks, but women in premature or early menopause need closer monitoring as this research indicates.

Reference: Zhu D et al. Age at natural menopause and risk of incident cardiovascular disease: A pooled analysis of individual patient data. Lancet Public Health 2019 Oct 3; [e-pub]. (https://doi.org/10.1016/s2468-2667(19)30155-0.

“The toxic effects of late-night living and all-day snacking are akin to those of ‘lead and asbestos'”according to Dr. Satchin Panda, a professor at the Salk Institute in La Jolla California. His podcast talks about the dangers of eating late at night and lack of sleep that can significantly effect the bodies circadian rhythm and raise inflammation.
According to Dr. Panda, “almost every gene, hormone, brain chemical, neurotransmitter, digestive juice and enzyme in our body is programmed to turn on and off, or go up and down, every 24 hours.”

During sleep, we produce growth hormone that helps repair damaged cells. If we get inadequate sleep, we have less of this growth hormone present to repair our cells. In addition, if we eat late in the evening, our stomach, pancreas, liver and other organs are unprepared and leaves little time for the body to repair itself. Over time, these conditions lead to chronic diseases such as diabetes, hypertension, dementia, acid reflux, and irritable bowel. Once you re-set your circadian rhythm, these problems can be fixed.

The simple solution (but not simple for many) is to eat all your food within an 8-12 hour window beginning about 30 minutes after awakening. Research found that when overweight people restricted their eating to a 10-hour window, they lost 4% of their body weight in 4 months without altering their diet.

Not eating at night and getting morning sunlight can synchronize our body clocks.
Do your best to eat your last meal around 6 PM.

STEM-Talk – Dr. Satchin Panda on Circadian Rhythms and Time-Restricted Eating to Improve Health

Detwiler, J. Timing is Everything: Adjust your daily clock to change your life. AARP The Magazine. Oct/Nov 2019 p. 50

New research reveals that the measles virus, if infected, can cause long term problems with the immune system. Even after you recover, the immune system is left weaker than before for several years which can make you vulnerable to other infections such as flu and pneumonia. The virus kills cells that apparently make antibodies leading to “immune amnesia”.

How do you know if you are immune?
1. Written documentation of age-appropriate vaccination
2. Laboratory test of immunity
3. Laboratory confirmation of having the disease
4. Even if born before 1957, you still need to have documentation of 2 vaccinations or antibody titers that show immunity.

Complications of adult measles can lead to pneumonia. One in 1000 adults will get encephalitis (brain infection).
One-two in 1000 children will die.
We have seen epidemic cases of measles this year in the U.S. as well as Europe. Of those infected, 71% were unvaccinated.
Make sure you have immunity to prevent acute and long-term complications.

www.cdc.gov>vaccines>acip.

We know that our blood pressure (BP) can reveal a lot about our cardiovascular risk factor for heart disease. About 50 years ago, the diastolic, or lower number, was the one causing more concern if elevated and more predictive of cardiovascular events (CV) than the systolic number. More recently, The systolic, or top number, may be deemed more important although both are important to maintain at normal levels (NEJM JW Gen Med Dec 15 2017 and J Am Coll Cardiol 2018; 71:e127).

A multivariable analysis (data collected on systolic and diastolic blood pressures) were collected to determine the 8 year CV outcomes (heart attack, stroke) in more than 1 million adults, average age 53, from North California’s Kaiser Permanente health system. The researchers found that for systolic BP’s of 136 and 160 mm Hg, the predicted 8 year risks for CV events were 1.9% and 4.8% respectively. On the other hand, for diastolic BP’s of 81 and 96 mmHg, CV event rates were 1.9% and 3.6% respectively.

This shows that both systolic and diastolic BP are independent predictors of adverse cardiovascular outcomes. In general, an ideal BP should be less than 130/80. Do you know your blood pressure?

Reference: Flint AC et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N Engl J Med 2019 Jul 18; 381:243

The current definition of a healthy body mass index (BMI) has been under some scrutiny after a new research study found that the BMI we consider “normal” may actually be too low and unhealthy.
A recent study collected data and adjusted results using a wider range of potential confounders (other variables) than in prior studies looking at measuring and interpreting BMI. The new data showed the impact of newer treatments to reduce cardiovascular disease illness and death while past studies relied on data from earlier times when less cardiovascular disease protection occurred. The current study included people from lower-income countries, although the finding is just as applicable to people who live in high-income countries, who were also included in the study population, noted Salim Yusuf, MBBS, principal investigator for the study.
The study showed that middle-aged adults with a body mass index of 25-29 kg/m2 (currently considered “overweight”) had a significantly better adjusted survival during an average follow-up of nearly 10 years than did people with a “normal” body mass index of 20-24 kg/m2 in a worldwide study of more than 140,000 people. This suggests that the current, widely accepted definition of normal body mass index is wrong.

This is where other tools come into play that can be better predictors for survival. One is the ratio of hand-grip strength to body weight. This assesses the importance of muscle mass to overall weight. The optimal strength/weight ratio is 0.42 in women and 0.50 in men according to Dr. Darryl Leong, a cardiologist at McMaster University and the Population Health Research Institute, both in Hamilton, Ont.
In a large longitudinal population study, it was found that grip strength measurement can be a strong predictor of cardiovascular mortality and a moderate strong predictor of cardiovascular disease. This new study, called the Prospective Urban-Rural Epidemiology Study (PURE) included about 140,000 people that were examined between 2003-2009. Grip strength was measured using a hand grip dynamometer.
Another very important and good predictor of weight is the waist/hip ratio which adds the dimension of the location of body fat rather than just the amount. An optimal waist/hip ratio for survival according to Dr. Leong is 0.83 in women and 0.93 in men. This means that a man whose hand/grip strength (in Kg) is half of the person’s body weight, then his chance for survival is very good.
So even though being “overweight” according to the BMI readings we currently use seems to lower mortality rates, we need to remember that the link between total mortality and BMI was strongest in the group of people that were on 1 or more treatments aimed at preventing cardiovascular disease (which may include being on a Statin drug or anti-hypertensive med) while there was no benefit among people not receiving any cardiovascular disease preventative measures.

https://www.mdedge.com/clinicianreviews/article/207836/lipid-disorders/survival-overweight-bmi-surpasses-normal
https://www.mdedge.com/anticoagulationhub/article/99720/acute-coronary-syndromes/grip-strength-predicts-cardiovascular

The CDC (centers for disease control) has now issued notices to warn people who are traveling to Europe about the risk for measles exposure. Measles outbreaks are occurring in England, France, Italy Greece and Germany. (https://wwwnc.cdc.gov/travel/notices/watch/measles-global).

Measles cases in Europe topped 41,000 in the first half of 2018 and included 37 deaths, with the highest incidence in children less than 1 year of age. This is more than twice as many reported annually between 2010 and 2017!! As in the U.S., low immunization rates are responsible for the rise. The popularity and ease of traveling to and from Europe accounts for many measles cases in the U.S.

In the U.S., measles cases have just exceeded 1000 which seems minimal compared to Europe even though it’s still quite high. The problem is that children who are unvaccinated are at risk while at home, but even more so when traveling to areas with continued measles circulation.

If you are traveling to Europe, consider:

1. Review your immunizations to assess the need for additional vaccinations. If you were born in 1957 or later then you should
get a measles titer to see if you still carry immunity to this virus.
2. Infants should be vaccinated starting at age 6 months if traveling to areas with measles outbreak.
3. Infants less than 6 months should delay travel until the child reaches 6 months of age.
4. Children over the age of 1 year should receive two-measles containing vaccines separated by at least 28 days prior to travel.
5. If you have traveled to these areas and develop a fever and rash, contact your health practitioner ASAP.

Although I understand the divided opinions about vaccines to be a real issue, I often stress to my patients when they are at significant risk for contracting the illness. This would be it!

Measles is a very contagious respiratory disease that spreads through the air by coughing or sneezing. Symptoms don’t appear until 10-14 days after exposure, so you could be a carrier and spread this virus and not know it. Complications include ear infections, pneumonia, encephalitis (brain infection) and problems during pregnancy. There are no treatments to this virus except treating symptoms with over the counter remedies to help discomfort. Those at highest risk are young children and the elderly. Don’t take chances and please talk to your practitioner about prevention through a vaccine.

Reference: Angelo KM et al. Spread of measles in Europe and implications for US travelers. Pediatrics 2019 Jul 1; 144e20190414

Glucosamine sulfate is a natural occurring chemical found in the body. It is used in the body to produce other chemicals that help build tendons, ligaments, cartilage and the fluid surrounding joints. This is where the supplement is touted as a pain reliever for osteoarthritis, especially with osteoarthritis of the knees. It may also slow the breakdown of joints and prevent the condition from getting worse. The effectiveness of glucosamine in patients with osteoarthritis and joint pain continues to be debated.

Now there’s another reason to consider using glucosamine…to lower the risk of cardiovascular disease (CVD). A prospective study was done in the U.K. where researchers examined the association between regular use of glucosamine and CVD risk in close to 500,000 people without known CVD at baseline. They completed a supplement use questionnaire where 20% of the respondents answered “yes” when asked if they used glucosamine regularly.

During a 7-year follow-up, 10,200 adverse CVD events occurred. After adjusting for multiple variables, regular glucosamine users had significantly lower risks for overall adverse CVD events including CV-related death, coronary heart disease and nonfatal stroke than did non-users.

These results are plausible considering glucosamine has anti-inflammatory properties and regular use is associated with lower levels of C-reactive protein, which is a marker for inflammation. It is best to wait for a randomized trial to repeat and confirm these findings as the study design (questionnaires) may not be as reliable.

One last thing is that the form of glucosamine supplement (glucosamine sulfate, glucosamine hydrochloride, N acetyl glucosamine) was not collected. Therefore it’s difficult to assess whether the association between various forms of glucosamine supplement and CVD risk might differ. Glucosamine is closely regulated in most European countries where it is only sold by prescription. However, in the U.S. and Australia it is a dietary supplement and sold over-the-counter where it is not regulated.

Ma H et al. Association of habitual glucosamine use with risk of cardiovascular disease: prospective study in U.K. Biobank. BMJ 2019 May 14;365:l1628.