Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

Cranberry versus antibiotic TMP-SMX for preventing recurrent urinary tract infections or UTI

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Is it better to take antibiotics rather than cranberry to prevent urinary tract infections?

Urinary tract infections including bladder infections are common amongst women. Literature supports the use of Cranberries and cranberry juice for preventing urinary tract infections (UTIs). Cranberry is popular because it is natural and devoid of puported side-effects related to antibiotics expecially over long term.

The study authored by Beerepoot and colleagues from the Academic Medical Center in Amsterdam was published in Archives of Internal Medicine. While the study showed antibiotics to be better at preventing UTI over 1 year, are they really supeior to Cranberry over longer term?

Not so fast! There is a subtext to the overall cost to one's health associated with antibiotic TMP-SMX use which I discuss after the author's conclusions.

Study methods: The study involved 221 premenopausal women with history of recurrent urinary tract infections (UTI). Subjects received either TMP-SMX 480 mg once a day or cranberry capsules 500 mg twice a day for 12 months.

Results

1. Mean number of UTIs Cranberry 4.0 vs TMP-SMX 1.8
2. Proportion of women with atleast 1 UTI Cranberry 78% vs TMP-SMX 71%
3. Median time to symptomatic UTI Cranberry 8 months vs TMP-SMX 4 months
4. Antibiotic resistence to E. coli (UTI bacteria) Cranberry 28% vs TMP-SMX 91%

Authors' conclusions: Use of TMP-SMX antibiotic is superior to cranberry for over a period of 12 months at the expense of antibiotic resistence.

My comments

1. The antibiotic group in this study likely had an inherent advantage since the bioavailabilty of active compound in the antibiotic greater than the cranberry capsule group (Clinical significance to be established).
2. The superiority of antibiotic TMP-SMX over 1 year not withstanding, the occurance of more than 90% antibiotic resistence gives me pause and makes me wonder if the results would have reversed if the study was extended over longer term, say 5 years.
3. The long term of use of broad spectrum antibiotic such as TMP-SMX is fraught with dangers, many not well understood including the effect on overall health due to disruption of the bacterial balance and homeostasis in the gut.
4. Many women have moved somewhat past cranberry alone and are using it in combination with mannose.

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Is kava kava bad or toxic for liver?

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Kava Kava and liver damage or toxicity (hepatotoxicity)

Author: Anil Minocha MD of Shreveport, LA

Kava kava akso known as kava Kava (Piper methysticum) root is widely used for treatment of  anxiety, depression and insomnia. Several reports have implicated in several  severe and even fatal  cases of hepatotoxicity. Immune-allergic mechanisms are believed to be involved in hepatotoxicity.

The regulatory causality evaluation of the reported cases has been mired in debatein the scientific community.  The Food and Drug Adminstration or FDA issued a customer advisory regarding the dangers of this agent in 2002. Its use is banned in several European countries.

Many experts like Anke have challenged  the concept of hepatotoxicity being caused by kava kava in many of the reported cases.  In vitro data does not support a hepatotoxic potential. Many of the effected patients reported in literature were also taking other medications.

Teschke in a thorough review published in Annals of Hepatology (2010) concluded  that kava kava may be hepatotoxic in a few individuals due to overdose, prolonged treatment, co-medication, and probably triggered by an unacceptable quality of the kava raw material. A 6-point program to improve quality by standardization to prevent liver toxicity due to kava has been recommeded.

Citation: Teschke R: Kava hepatotoxicity--a clinical review. Ann Hepatol. 2010;9(3):251-65.

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Saccharin, aspartame and cancer risk

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Cancer risk and consumption of arificial sweeteners especially saccharin, aspartame

 

• There has been an ongoing controversy over the health risks especially cancer risks due to consumption of artificial non-nutritive sweeteners like saccharin and aspartame. Most of the data about cancer risk has been based on animal studies. Question arises: What is the human data on cancer risk due to artificial sweeteners due to saccharin and/or aspartame.

  Gallus and colleagues from Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.provided an analysis of the integrated network of case-control studies between 1991 and 2004 in Italy on variety of cancers. The findings were published in the journal Annals of Oncology. The odds ratios for saccharin use and cancer risk are as follows:

  • Oropharynx 0.83 (95% CI 0.30-2.29)
  • Esophagus 1.58 (95% CI 0.59-4.25)
  • Colon 0.95 (95% CI 0.67-1.35)
  • Rectum 0.93 (95% CI 0.60-1.45)
  • Larynx 1.55 (95% CI 0.76-3.16)
  • Breast 1.01 (95% CI 0.77-1.33)
  • Ovaries 0.46 (95% CI 0.29-0.74) --------------Reduced risk
  • Prostate 0.91 (95% CI 0.59-1.40)
  • Kidneys 0.79 (95% CI 0.49-1.28)

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• Oral cavity and pharynx 0.77 (95% CI 0.39-1.53)
• Esophagus 0.77 (95% CI 0.34-1.75)
• Colon cancer 0.90 (95% CI 0.70-1.16)
• Rectum 0.71 (95% CI 0.50-1.02)
• Larynx 1.62 (95% CI 0.84-3.14)
• Breast cancer 0.80 (95% CI 0.65-0.97) --------Reduced risk
• Ovaries  0.75 (95% CI 0.56-1.00)
• Prostate 1.23 (95% CI 0.86-1.76)
• Kidneys 1.03 (95% CI 0.73-1.46)

 

 

In fact there was a significant less likelihood with use of total sweeteners and the risk for breast and ovarian cancer. On the other hand, there was a significant trend for total sweetener consumption and for laryngeal cancer.

Conclusion of the study: The authors concluded that there is a lack of association between saccharin, aspartame and other sweeteners and the risk of several common neoplasms.

Update of above analysis for more cancers and sweetener risk: Bosetti and colleagues examined the role of sweeteners on cancer risk especially saccharin and other artificial or low-calorie sweeteners including aspartame. They conducted an update of their analysis of an integrated network of case-control studies conducted in Italy between 1991 and 2004 including data on cancers of the stomach, pancreas, and endometrium. The findings were published in the journal Cancer Epidemio Biomarkers Prev (2009).

The invesigators found that after adjusting for confounding factors, odds ratios (indicating less or more risk; if you just want conclusions, just scroll down) ever users of sweeteners versus nonusers were as follows:

• Gastric cancer 0.80 (95% CI, 0.45-1.43)
• Pancreatic cancer 0.62 (95% CI, 0.37-1.04)
• Endometrial cancer 0.96 (95% CI, 0.67-1.40)

Conclusions of the updated cancer risk study: The authors concluded that the findings lent further support to the evidence on the absence of an adverse effect of low-calorie sweetener (including aspartame) consumption on the risk of common cancers in the Italian population.

 

What do you think about the health risks due to artificial sweetners including cancer and metabolic risks? please share your thoughts. 

 

 

 

Vitamin D deficiency: Is it a growing epidemic

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Vitamin D or calciferol is actually a group of compounds with the molecule comprised of a cholesterol backbone. 1,25(OH)2-vitamin D is the physiologically active form of vitamin D. Several of the metabolites are biologically active.

Sources of vitamin D:

Body vitamin D include is derived from production in skin as well as intestinal absorption.

Skin: Exposure of skin to sunlight leads to production of vitamin D in body.

Diet: In addition to vitamin D fortified milk, the dietary sources rich in vitamin D include fatty fish, cod-liver oil, and eggs. Vitamin D2 or ergocalciferol, a plant steroid is used for milk fortification. Other products that may be fortified include cereals, breads etc. Diet usually provides Vitamin D3.

Vitamin D homeostasis:

Factors involved in vitamin D homeostasis include parathyroid hormone, serum calcium, and phosphorus levels, estrogen, placental growth hormone, and prolactin etc.

Functional significance of vitamin D:

Vitamin D and its metabolites are intricately related to calcium homeostasis and bone metabolism. With increasingly limited exposure to sun, Vitamin D insufficiency as measured by low levels of 25-OH vitamin D is a growing epidemic across the world especially among adolescents and the elderly.

 

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Pathologic disease states with vitamin D involvement:

 

Although rickets in rare these days, subclinical vitamin D deficiency is common.

Since calcium metabolism is involved in not just in numerous metabolic functions in the body including bones, vitamin D deficiency may play a role not just in osteoporosis but also in impairment of immune function,increased risk of various malignancies including colon cancer as well as increased risk for heart disease.

Cancer: An increase of 25 nmol/L in 25-hydroxy-vitamin D levels is associated with a 17 percent decrease total cancer risk.

Bone fractures: Vitamin D and calcium supplementation reduces the risk of falls and fractures.

Vitamin D levels and mortality: Low levels of vitamin D are an increased risk of all cause mortality whereas supplementation of vitamin D results in reduced of all-cause mortality

Vitamin D levels: Best marker is the serum 25-OH vitamin D concentration. While there are considerable disagreements on the “normal” , a level below 20 to 30 ng/ml is considered abnormal. The "normals" may vary with the labs as well.

Vitamin D deficiency:

Vitamin D deficiency can be seen in 57 percent of hospitalized patients of whom 22 percent are severely deficient [Thomas 1998] Vitamin D stores decline with age, especially in the winter because of reduced sun exposure.

The deficiency or resistance may occur due to inadequate dietary intake, malabsorption, lack of sun exposure, liver or kidney dysfunction,or there may be end-organ resistence to vitamin D metabolites. Chronic use of corticosteroids results in decreased vitamin D dependent calcium absorption and hence bone disease.

 

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Dose of vitamin D:

The tolerable upper intake level for vitamin D for healthy adults is 2000 IU per day. A minimum of 200 IU per day is needed in healthy adults.  Many experts argue that the normal daily dose of vitamin D should be 1000-2000 IU per day. Some patients may even require higher doses and should be undertaken under close medical supervision.

Pregnant and lactating mothers: 400 IU/d

Infants who are exclusively breast fed: 400 IU/d. Since infant formulas are fortified with vitamin D, formula-fed infants require supplementation if they consume less than 1000 mL daily of formula.

Elderly: 800 IU/d plus atleast 1.2 g of elemental calcium per day.

Special cases:  

Patients noncompliant with daily vitamin D therapy may benefit from high dose intermittent therapy (100,000 units every four months).

Prevention and treatment of osteoporosis 800 IU (20 micrograms) per day. 

Toxic dose of vitamin D: Greater than 2000 IU per day.

 

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Toxicity of vitamin D:

Vitamin D is not innocuous and excess ingestion can lead to vitamin D intoxication. Subjects prone to this include not only those those who consume megadoses of supplements but also in patients on vitamin D replacement therapy for a variety of disorders. Manifestations of toxicity include hypercalcemia, hypercalciuria, altered mental status, polyuria, polydipsia, anorexia, vomiting, muscle weakness, and bone demineralization with pain.

Caveat:

I would like to pint out that some experts have questioned the issue of extent of prevelance of vitamin D deficiency for a variety of good reasons including in part to the paucity of reliable and reproducible blood tests and that the need for vitamin D may be different in different population sub-groups.

 

Are you taking any vitamin D supplements? If so, what dose and have you talked to your doctor about it? Have you had your vitamin D levels checked? Please share your thoughts.

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Disclaimer: Everything on this site including the blog and the ads are for your information only. . Please do your own due diligence and consult your health care professional advisor. The ads have potential to generate income for the blogger.

 

Iron supplements and leaky gut or intestinal permeability

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The effect of iron supplementation on intestinal permeability was examined as part of a randomized iron plus multi-micronutrient (without iron) supplementation trial in Zambian children (n=153; mean age 10.2 years) over period of ten months.

Iron supplementation resulted in a higher lactulose to mannitol ratio indicating increased intestinal permeability as compared to controls whereas there was no impact of no effect of multi-micronutrient supplementation. The authors (Nchito and colleagues) speculated that this could in part explain the deleterious health effects of iron documented in some studies.

Preponderance of evidence suggests that unselected addition of multiple micronutrients to iron supplementation in children with iron deficiency anemia only marginally improve response as assessed by hemoglobin; on the other hand, these additional unselected micronutrients may have an adverse impact of their own and the routine use for treatment of iron deficiency anemia may not be justified.

Bottom line is everything should be in moderation; iron can be toxic; you should take iron if you need it, but be sure that you do actually need it in consultation with your physician.

Are you taking iron supplements? Have your iron levels been checked on periodic basis? Please share your thoughts.

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 Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Entericoated aspirin, NSAIDs ulcers, dannon yogurt, FDA approved, medical radiation, rotavirus vaccination

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Patients concerned about side effects of aspirin especially the risk of gastrointestinal ulcers often take entericoated formulations of aspirin to avoid such complications.

Though patients often believe these pills pose a lower risk of stomach upset, they actually don’t appear to have much effect on the more serious damage that aspirin can cause.

 

“That’s a huge misunderstanding,” says David A. Johnson, a past president of the American College of Gastroenterology and a professor at Eastern Virginia Medical School. Read more here.

Dannon must pay consumers up to $45 million in damages for falsely advertising the health benefits of its yogurt, under the terms of a class action settlement reached Tuesday in federal court in Cleveland, reports Cleveland.com. The targets of the class action were two Dannon yogurt products -- Activia and DanActive -- pitched in TV ads by actress Jamie Lee Curtis. Read more at dannonsettlement.com.

 The terms "FDA approved" or "FDA registered." are reassuraing while purchasing health care products.  According to Daniel Carpenter, professor of government at Harvard University, and as published in Los Angles Times, these words "FDA approved" or "FDA registered" don't mean as much as consumers often assume. "FDA certification of a product is never a guarantee of safety or effectiveness of anything," Carpenter says.

A House subcommittee heard from various experts calling for standardization of medical radiation to enhance effectiveness and safety as reported in the New York Times, Saying that recent news reports about radiation accidents had “raised huge concerns for me,” Frank Pallone Jr. the chairman of the Energy and Commerce subcommittee on health, said he was shocked that the people who operate radiologic devices need not be licensed in many states and that “the requirements to report errors and the penalties for making errors are basically nonxistent or not enforced.”

The efficacy of the pentavalent rotavirus vaccine was assessed among infants in the United States was studied by Wang et al. from Harward University. A large, national, health insurance claim database was studied. Use of the vaccine resulted in a 66% decrease in acute gastroenteritis related hospitalization and visits to emergency rooms as well as a 74% reduction in costs.

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Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

 

Fish type, mercury and heart benefits

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 Fish type, omega-3 fatty acids, mercury toxicity and heart (based in part on  Nature Clin Practice (2008). 

Fish contain high amounts of omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) which have been proven to be cardioprotective, i.e. good for heart. They prevent heart attacks.  Studies suggest that there is 29% reduction in mortality over 2 years inpatients who have had heart attacks.

The evidence is strong enough for the American Heart Association to recommend increased intake of omega 3-fatty acids. The good news is that mercury content of all the fish is not the same. The mercury content of predatory fish is much higher because they eat other fish containing mercury and indirectly attain much higher levels mercury than the fish at the lower end of the food chain.

The beneficial effect if fish intake can be demonstrated with as few as 1 fish per week, and greater intake provides even greater protection.

Fish, mercury and toxicity: The benefits of fish intake are tempered by the concern over mercury intake through fish and the resultant potential for neurotoxicity.

Low versus high mercury fish: The good news is that mercury content of all the fish is not the same. The mercury content of predatory fish is much higher because they eat other fish containing mercury and indirectly attain much higher levels mercury than the fish at the lower end of the food chain.

Identifying low versus high mercury fish: Sardines, salmon, and shrimp have lower mercury content than the predatory sharks, tuna, sword fish and orange roughy.

Farmed fish: Even more importantly, the farmed fish have the lowest mercury content while providing the perhaps similar benefits.

It should be pointed out that some farmed fish like tilapia and catfish may have omega-fatty acid profile may be pro-inflammatory, sadly it is the cheaper ones!

Limiting the mercury content: The exposure to mercury can be lowered by limiting the amount of fish ingested and eating the fish with lower mercury content.

Recommendations for fish intake: Institute of Medicine provides conservative recommendations regarding fish consumption. Non-pregnant persons may eat 1 predatory fish meal and 2-3 low mercury fish meals per week. Pregnant women should not eat more than 1 predatory fish meal per 2 weeks; however they may eat other fish 2-3 times per week.

Both wild and farmed fish are beneficial (note the caveat/exception above in text).

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Disclaimer: Everything on this site is for your information only. Do your own due diligence and consult physician. The ads have potential to generate income for the blogger.

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Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger. 

Risks of acid blocking PPI heartburn drugs keep piling up

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Side effects of acid suppression by proton pump inhibitors

 Proton pump inhibitors or PPIs (Prilosec, Prevacid, Nexium, Protonix, Aciphex) have been a big boon to the chronic heartburn or GERD sufferers.

These PPI drugs started with a black box label warning of serious consequences of cancer to being used indiscriminately almost like a candy. Data indicate that a substantial proportion of long-term PPI users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment.

Long term use of proton pump inhibitors is providing us increasing information on their potential harmful side effects. Recent data about PPIs suggests the following:

1. Increased risk of serious intestinal infections with Clostridium difficile bacteria
2. Increased risk of bone fractures
3. Bad breath
4. Pneumonia
5. Bacterial overgrowth
6. Diarrhea and microscopic colitis
7. Vitamin B12 deficiency
8. Chronic muscle disease (myopathy, polymyositis)

Click to read about  How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux

 Read about Dr. Minocha's article on PPIs and C. difficile infection 

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Heartburn drugs may cause bad breath

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It is believed that chronic heartburn or gastroesophageal reflux disease (GERD) causes bad breath or halitosis. Acid blocking medications have often been used for this purpose. Now comes a study suggesting that the opposite is in fact true, i.e. the potent heartburn drugs of the proton pump inhibitor (PPI) class e.g. Aciphex, Prilosec, Prevacid, Nexium, Protonix etc. may actually cause bad breath.

Dr. Camacho-Lobato and colleagues from Brazil recently presented their findings at the American College of Gastroenterology meeting in Las Vegas in October 2006 (Poster#8).

Click to read about  How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux

The researchers studied 23 consecutive adults with GERD. And compared them to 17 patients with dyspepsia or indigestion. Patients with oral or dental disease were excluded. Oral volatile sulphur compounds that cause bad odor in breath were measured.

These investigators found that bad breath occurred in 39 percent of the GERD as compared to only 18% in those with dyspepsia.

Because of their potent acid blocking activity, PPI have potential to cause small bowel bacterial overgrowth thus causing bad breath.

This study represents a classic chicken and egg story. Is it that GERD causes bad breath and patients were simply taking PPIs to alleviate GERD. The reverse is also possible, i.e. the halitosis occurs due to acid blocking by these drugs in GERD, and contributes to the bad breath problem caused by GERD itself also.

Do you have chronic heartburn and/or bad breath? What measures do you take for these problems?

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Home Shreveport page Facebook Anil Minocha

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Direct consumer drug advertising

Knowledge is power. Sunshine is a great disinfectant.

Despite these well known and agreed upon principles, I have mixed feelings about direct to consumer advertising by the drug companies. ONe of the recent ones to enter this arena is the commercials for Orlistat or Xenical®, the drug used for obesity.

Considering the fact that obesity is rampant in our society, it would appear to be a wise choice. DTC campaigns certainly make the consumer aware of the products and its potential applicability to him or her.

On the other hand, there is potential for people to quit doing the appropriate life-style changes (diet and exercise) in favor of pharmacological cure! Many people in the health-care community fear that there is over-use of medications as a result of such consumer-oriented campaigns.

Where do you stand on this issue? Do you think that the benefits of such consumer-targeted campaigns outweigh the possible overuse?

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger

Proton pump inhibitors and diarrhea

Clostridium difficile-associated diarrhea usually occurs as a result of antibiotic use and can be potentially life threatening. The role of body defenses especially gastric acid secretion as a risk factor has not been fully elucidated.

Proton pump inhibitors (PPI: Nexium, Prevacid, Protonix, Prilosec, Aciphex) are frequently prescribed for acid reflux, peptic ulcers etc. They act by causing suppression of gastric acid secretion which is an important component of defense mechanism against infections.

Dr. Yearsley and colleagues studied the impact of acid blockade by chronic PPI therapy as a risk factor for development of C. difficile diarrhea and published their findings in the journal Alimentary Pharmacology Therapeutics (August 2006).

These investigators performed a case controlled study with 155 C. difficile diarrhea patients. They found that among the C. difficile-associated diarrhea group, 41% had received acid suppression with PPIs 26% of controls. This translates into the fact that chronic PPI therapy almost doubles the risk of C. difficile diarrhea.

Click to read about  How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux

Take home message: Since antibiotics are the predominant cause of C. difficile associated diarrhea, the risk of concurrent therapy with PPI should be carefully weighed in patients taking antibiotics.

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger