Our circadian rhythm influences the pharmacokinetics (how the body processes a drug) of many blood pressure (BP) medications. The peak activity of the system that regulates body fluid balance and blood pressure in our bodies, called the renin-angiotensin system, works the best during sleep. This is why a few small studies have suggested that BP medications might be most effective if taken at bedtime.

Research was done on more than 19,000 primary care patients with hypertension. The two groups had similar BP levels and physiological, comorbidity and laboratory (cholesterol) levels. Patients were asked to take their medication regimen either at bedtime or on awakening. Patients were followed with rigorous BP monitoring for about 6.3 years.

The results showed significantly lower BP readings in those that took their blood pressure medications in the evening compared to those taking them upon awakening. The incidence of cardiovascular related death, myocardial infarction, heart failure and stroke was significantly lower in the bedtime group than in the awakening group (6.5% vs 11.9%)- a nearly 50% relative reduction.

This large randomized trial shows convincing evidence that patients with high blood pressure will have better cardiovascular outcomes if they take their medication at bedtime. There was also no adverse events with this group such as fainting or falling on awakening. The only antihypertensive medications that should be taken in the morning are those that have a diuretic such as hydrochlorothiazide.

Reference: Hermida, RC et al. Bedtime hypertension treatment improves cardiovascular risk reduction. The Hygia Chronotherapy trial. Eur Heart J 2019 Oct 22; [epub]. (https://doi.org/10.1093/eurheartj/ehz754).

The coronavirus has and will continue to get lots of attention in the weeks and months to come. There are two main reasons why this virus, known as COVID-19, is getting such attention. First, it can kill healthy adults in addition to the elderly, especially those with other health problems and weakened immune systems. It is interesting that this infection is either mild or nonexistent in children. There have been no pediatric deaths and very few kids even seem to get sick (Great news for parents!).

Second, COVID-19 is transmitted easily. The average infected person spreads the disease to 2-3 people. That is a significant rate of increase. Evidence is showing that it can be transmitted by people who are just mildly ill or not showing any symptoms. This may be why this virus will be difficult to contain.

This is why we should be cautious and informed through the right sources such as researchers and scientists who actually are monitoring this virus which is the CDC and World Health Organization (WHO). Listening to government officials or a non-medical resource may give you false information.

What we do know is that on average, seasonal flu strains kill about 0.1% of people who become infected. Early estimates of the coronavirus death rate from Wuhan, China have been around 2.0 percent. But the death rate may be even lower if, as many experts suspect, there are many mild or symptom-free cases that have not been detected or accounted for. So the true death rate could be below 1 percent, similar to that of a severe flu season according to Dr. Anthony S. Fauci and Dr. H. Clifford Lane, of the National Institute of Allergy and Infectious Diseases, and Dr. Robert R. Redfield, director of the Centers for Disease Control and Prevention. Even if the death rate is low, an infectious disease can take a toll if enormous numbers of people catch it. As of this week, there are about 87,000 coronavirus cases and 3000 deaths. The number of cases continues to expand outside of China.

So what can we do?

1. Wash your hands…alot! Best results are to wash for at least 20 seconds.
Alcohol based hand sanitizers are also good. Try not to touch your face which is where germs tend to migrate.
2. If you have a cough, and especially a fever, please stay home from school or work. Your teachers and employers will understand with how sensitive this situation has become.
3. Avoid traveling to the main areas where coronavirus is spreading quickly, including China, Italy, Iran and South Korea.
4. Consider getting a flu vaccine if you haven’t done so already. We may find out that it could give some residual immunity, but mainly because you don’t want to get a double “wammy” and end up in the hospital. Flu season is still upon us.

What NOT to do?

1. Panic!! No need to be ordering a years worth of your prescription medications, oxygen, water and hoarding canned goods and other supplies, building bunkers and preparing to go off grid…don’t do that.
2. Masks are helpful if you have the coronavirus or the flu to avoid the spread of disease. But stocking up on masks and gloves causes a shortage for the people who really NEED it, like medical professionals and hospital staff.

As you can see, the list of what to do is the same list that is recommended for cold and flu season minus the travel restrictions. Although I have always recommended to avoid being around people that are sick.

This article may give you an overview of coronaviruses and why this one is unique.

Learn about the Coronavirus

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.