Insane Medicine – High Blood pressure and the new Rules

Insane Medicine - Blood pressure cuff
Insane Medicine – Blood pressure cuff
  • Blood pressure is force that is exerted on your arteries with every heart beat, with the systolic pressure (top number) being the peak pressure the moment the hear contracts, while the diastolic number (bottom number) is the pressure when the heart relaxes. There is always residual pressure in the circulatory system when the heart is at rest due to the elastic, expansile ability of veins and arteries in the cardiac cycle that expand and collapse with each heart beat.
  • normal blood pressure is anything less than 120/80
  • When a person develops high blood pressure, that puts stress on the vital organs inside the body, especially the brain, heart, and kidneys. This increases your risk of stroke, heart disease, and kidney failure. Vascular dementia due to damaged vessels and strokes in the brain results in dementia.
  • As people age, high blood pressure becomes more and more common, with ~70% having high blood pressure by the age of 65-74.
  • There have been recent changes in the blood pressure goals per a recent report by JNC-8.  If you are age 60 or older, any blood pressure up to 150/90 mm of Hg is acceptable, unless you have diabetes, in which case 140/90 mm Hg is the acceptable goal. This new goal has not been accepted by all the medical authorities.
  • The American Society on Hypertension (ASH) suggests that patients age 80 and over should be allowed to have a blood pressure up to 150/90, unless they have high risk issues like diabetes or kidney disease, in which the 140/90 upper limit should be used. If the person is less than age 80, then 140/90 is the upper limit of acceptable and probably a goal of 130/80 should be used if they have poor heart function or kidney disease.
  • Which target should you be using? Ask your doctor, but it seems reasonable to be more aggressive with blood pressure treatment if you have diabetes, kidney disease, protein in your urine, or heart disease.
  • Lowering a person’s blood pressure too low may make them dizzy when they stand or even pass out due to low blood pressure. This is something we want to avoid!
  • First line treatment includes lifestyle changes such as dietary modifications such as reducing salt intake and eating more antioxidant-rich fruits and vegetables. Physical activity is a key component as well.
  • Have your doctor check for possible secondary causes of high blood pressure such as ‘white-coat’ hypertension (stress in the doctor’e office that goes away when you measure blood pressure at home). Also medications such as prednisone, or over-the-counter agents for colds and cough can increase blood pressure. Have your doctor review your non-prescribed medicines.
  • Have your doctor consider looking for thyroid disorders, kidney disorders, or sleep apnea that can elevate blood pressure.
  • Keep track of your home blood pressure with a home blood pressure cuff that is properly calibrated and used. This can be more accurate when properly done than a doctor’s office single reading of blood pressure.
  • For those who need medications, doctors will start low and titrate medication upwards slowly. There is more evidence that ACE inhibitors or ARB inhibitors mixed with amlodipine ( a calcium channel blocker) are excellent first line therapies. Beta blockers are not in favor for primary or secondary use unless there is some specific reason to be taking them (such as heart disease). Be prepared to take two or even three medicines to control your blood pressure.
  • Again, the best treatments to start with are lifestyle modifications! Lose weight, take in less salt. Consider following the DASH diet!

The DASH diet to help control high blood pressure:

Insane Medicine – Parasites – Cyclospora in food

Insane Medicine - Cyclospora - a cause of food poisoning that results in diarrhea illness
Insane Medicine – Cyclospora – a cause of food poisoning that results in diarrhea illness
  • We don’t think much of parasites in the United States as a source of illness because they seem like such tropical diseases, however, there are quite a few problems caused by parasites here, some that are transported to us, especially on food. Recently, in Texas, an infection caused by a protozoan, Cyclospora cayetanensis resulted in diarrhea-type illness in Texas. The culprit was cilantro imported from Peubla, Texas!
  • Cyclospora has been an occasional culprit of gastrointestinal infections in the United States. it is not endemic, but rather is tropical or sub-tropical in it’s origins.
  • It is a single celled organisms that is spread from fecally contaminated food and water.
  • Food products that have been found to carry Cyclospora in past outbreaks include snow peas, raspberries, and basil. No frozen products have been associated with outbreaks. It can occur at any time of the year but mostly in spring and summer months.
  • Symptoms of infection develop in a week, resulting in abdominal bloating and cramps, with primarily diarrhea, less often, there may be vomiting. Infected people can lose a lot of weight. Symptoms may last weeks to months with diarrhea alternating with constipation even.
  • It is diagnosed by examining stool for the parasite specifically. There is no blood test for this. Its’s treatment is with a sulfa- based antibiotic (trimethoprim-sulfamethoxazole).
  • Cyclospora is not killed by routine disinfection and sanitation measures, but it is best to wash fruit off thoroughly.
  • Do you have this infection? Unlikely, but in a group setting of infection, especially with the symptoms listed above, it is something to consider.  <— Link to prior outbreaks of Cyclospora in the United States.

Insane Medicine - Cyclosporiasis life cycle - from CDC
Insane Medicine – Cyclosporiasis life cycle – from CDC

Insane Medicine – High Cereal fiber intake is associated with decreased cardiovascular risks after a heart attack

  • Fiber plays an improtant role in our diet. Evidence shows that high amounts of cereal fiber intake is associated with decreased cardiovascular risk after a first hear attack.
  • There are two forms of fiber. Insoluble fiber, which dissolves in water. Examples of this include oats, beans, peas, apples, rice bran, barley, citrus fruits, strawberries, rice, and peas. Examples of insoluble fiber include whole wheat bread, brussel sprouts, rye, grains, cabbage, carrots, turnips, and apple skins.
  • The goal of intake for fiber is 25 grams a day, which would be the equivalent of 6 cups of oatmeal (cooked) a day, as an example.
  • Increasing you rcereal fiber intake after your first Heart attack results in a 35% decrease in risk of death from cardiovascular causes and a 31% decrease in death from any cause.
  • Increasing fiber intake works by improving your glycemic response and insulin  sensitivity. This decreases LDL cholesterol and diabetes risks. You will eat less because you feel full after high fiber meals and ths will tend to lose more weight.
  • Eating fibers from fruits is less associated with improved outcomes after a first heart attack than cereal fibers.
  • You need to aim for 6-8 servings of grains per day and 8-10 servings of vegetables and fruits per day. Remember that a half-cup of fruit is a serving while a single cup of leafy vegetables is a full serving.

Insane Medicine – Key factors to prevent cognitive decline and dementia.

Insane Medicine -Preserve your mind to prevent cognitive decline
Insane Medicine -Preserve your mind to prevent cognitive decline.
  • Alzheimer’s disease results from accumulation in the brain of aberrant proteins (amyloid-beta and tau). This results in faulty connections in the brain and brain cell death. With that, memory and skills are lost over time.
  • 30 million people are affected by Alzheimer’s disease in 2010. One-third of these cases are attributable to modifiable risk factors such that there is a chance to prevent cognitive decline in some people. (Lancet Neurology, 2014)

There are controllable risk factors: What are they?:

  1. A lack of exercise.
  2. Smoking
  3. Poor diet
  4. Low level of education
  5. Depression
  6. Poor lifestyle
  7. Obesity
  8. High Blood pressure
  9. Uncontrolled diabetes.
  • Keeping a healthy hear may prevent dementia, in that reduced blood flow to the heart due to no exercise or poor diet also impacts flow to the brain as well. The above factors overlap in that depressed people may smoke more and get less exercise. They gain weight and also eat poorly.
  • Per the JAMA (July 2014) there has been a 24 % drop in first time strokes and a 20% drop in death from strokes. This is due to better control of risk factors causing strokes such as treating elevated blood pressure, stopping smoking, and statin use to control cholesterol levels.
  • It is important to stimulate your brain with mental activities and mental challenges such as cross-word puzzles or card playing. This resulted in greater brain volumes, especially in the hippocampus and better memory and executive functioning.
  • Moderate exercise in the 50-65 year range decreases the risk of cognitive decline significantly. The same was true for even older individuals (70 and above). SO be certain to exercise 30 minutes a day at least 5 days a week!

Insane Medicine : Testosterone – who needs it?

Insane Medicine -Depo-Testosterone 200 mg per ml injection Testosterone cypionate
  • Testosterone is a hormone with many biological effects. It binds to androgen receptors in the body, or is converted to  dihydrotestosterone,(via the enzyme enzyme 5-alpha-reductase ), which then can bind to androgen receptors in the body. Testosterone can act like an estrogen as well after being converted to estradiol via an aromatase.
  • Dihydrotestosterone’s main action is on the external genitalia and prostate in men, while testosterone affects muscle maintenance and strength. The estradiol function of testosterone affects sexual functioning and decreases body fat in men. Likewise, it has an effect on bone mass.
Insane Medicine - The hypothalamus  releases a gonadotrophal releasing hormone that stimulates the pituitary to make FSH and LH that, in turn, stimulates the testiles to produce testosterone.
Insane Medicine – The hypothalamus releases a gonadotrophin releasing hormone that stimulates the pituitary to make FSH and LH that, in turn, stimulates the testicles to produce testosterone.
  • Symptoms suggestion androgen (testosterone) deficiency include low libido, loss of erections,  low bone mineral density, enlargement of the breasts, anemia, decreased muscle mass, decreased energy, and increased body fat.
  • The goal for testosterone replacement in males is to increase libido, muscle mass restoration, increase fat-free mass, increase bone density, and decrease body fat.
  • Testosterone should be measured in the morning on three different occasions, as there is a circadian rhythm in testosterone secretion. If it low each time and the patient has symptoms consistent with testosterone deficiency, then replacement would be indicated. Again,  low libido, decreased morning erections, loss of body hair, low bone mineral density (BMD), gynecomastia, and small testes suggest a need for treatment.
  • In appropriate candidates, testosterone replacement leads to improved muscle strength and fat-free mass. Bone density can also improve as well by as much as 40% in patients who are hypogonadal (low testosterone).
  • As for sexual dysfunction, Testosterone replacement may  increased sexual desires, but that maynot necessarily result an increased satisfaction rate.
  • Testosterone seems to render no improvement in cognitive abilities in patients.
  • Risks of testosterone replacement include the potential to increase the risk of prostate cancer, worsen sleep apnea, increased risk of venous thromboembolism (blood clots in the legs), andpotential increased cardiovascular risks.
  • Thus – using testosterone is best saved for those with clear indiciations. Consult your doctor. More later on all this.
Insane Medicine - Testosterone
Insane Medicine – Testosterone


Insane Medicine – No sugars are health foods: Coconut palm sugar is not healthful – it’s just sweet!

Insane Medicine - Coconut-Palm-Sugar
Insane Medicine – Coconut-Palm-Sugar
  • Coconut palm sugar is a sugar alternative from Southeast Asia made from the flowering buds of a coconut tree. It has minimal processing in it’s production.
  • It is not highly nutritious in vitamins and minerals, but rather it is just sucrose and does not have a low glycemic index. It does not help in weight control or prevent cancer.
  • It’s use is mainly just for it’s taste, which is a more caramel flavor, and is useful in cooking and baking. Consider coconut palm sugar to be empty calories otherwise. There is no proof of health benefits to using it.

Insane Medicine tip- Eat at least two 3.5 ounce servings of fish per week!

Insane Medicine - canned salmon
Insane Medicine – canned salmon
  • The American Heart Association recommends that you eat two 3.5 ounce servings of a fatty, omega-3- rich fish every week. Salmon and Albacore tuna are examples of such fish.
  • Omega-3 fatty acids decrease platelet stickiness and decrease your chances of a heart attack. They also reduce your triglyceride levels and prevent heart rhythm abnormalities. They also decrease inflammation in the body.
  • Canned salmon is generally obtained from wild salmon and tends to have less PCB’s (polychlorinated biphenyl) that is found in plastic containers. Salmon is low in mercury, which is great!

Insane Medicine – It’s the dietary pattern that matters for heart health! Saturated fats – good or bad?

Insane medicine -butter
Insane medicine -Based on current evidence, per the Annals of Internal Medicine, there is no support for encouraging high consumption of polyunsaturated fats and low consumption of saturated fats.
  • The recent Annals  of Internal Medicine (2014) study mentioned in the photo above , reviewed the harm of saturated fat and found a poor connection between saturated fat consumption and cardiovascular risks based on a meta analysis of 600,000 people.
  • Fatty acids are classified as saturated, monounsaturated, or polyunsaturated. Nutritional guidelines generally encourage low consumption of saturated fats, high consumption of ω-3 polyunsaturated fatty acids from fish or plant sources, and avoidance of trans fats, particularly those from partially hydrogenated fat, to promote cardiovascular health.
  • The Annals study found no associations between total saturated fatty acids and coronary risk. The study found a “possible inverse association between circulating margaric acid (an odd-chain saturated fatty acid that is moderately correlated with milk and dairy fat consumption) and coronary disease, suggesting that odd-chain saturated fats, which reflect milk or dairy consumption, may have less deleterious effects in risk for coronary heart disease.”  Again, to summarize this, margaric acid, a saturated fat found in dairy, seemed to lower the risk of heart disease. So you can increase your low fat dairy intake.
  • Omega-6 polyunsaturated fats, found in vegetable oils and processed foods were linked to higher cardiac risks.
  • Trans-fatty acid intake increases risk of heart disease in this same study and monounsaturated fat has no effect on heart disease.
  • Circulating levels of eicosapentaenoic and docosahexaenoic acids (the 2 main types of long-chain ω-3 polyunsaturated fatty acids) and arachidonic acid are each associated with lower coronary risk in this study,.  ω-3 and ω-6 polyunsaturated fatty acid supplements did not help heart health.

Summary for what you should do:

  • This doesn’t mean you can eat all the saturated fats you want or replace them with processed food. Eating a lot of cream and fatty meats would be harmful in all likelihood.
  • Follow the Dietary Approaches to Stop Hypertension (DASH) Plan and the Mediterranean-type diet.
  • Be certain to follow a healthy pattern of eating, including vegetables, fruit and whole grains, legumes, nontropical vegetable oils and nuts. Include low-fat dairy products, poultry, and fish. Watch out for processed foods and limit sweets and sweetened beverages and red meat.
  • It is the pattern of eating, not the individual choices that affects your cardiac risk.

Insane Medicine – Probiotics for inflammation, gut health, antibiotic-associated diarrhea, and many other things!!

Insane Medicine - probiotics help!
Insane Medicine – probiotics help!
  • The symbiotic organisms found in the gut and elsewhere are called “probiotics.” These organisms help metabolize foods, absorb nutrients, prevent pathogenic colonization, and  help maintain intestinal health by living within our gut and competing with other unhelpful bacteria.
  • Some foods have probiotics added in them, such as: yogurt, kefir, kombucha tea, cheese, buttermilk, fermented cabbage like sauerkraut, and kimchi,  and acidophilus milk.
  • Lactobacillus species, Bifidobacteria species, and Saccharomyces boulardii are the most commonly used probiotic species used. Lesser probiotics include Streptococcus thermophilus 
  • Processed foods do not have live probiotic organisms. The processing kiolls the organisms. Look for labels that say “contains live active cultures.”
  • Probiotics work by competing with the growth of harmful bacteria in the gut by taking up space and nutrients. Siome produce antibacterial substances, such as hydrogen peroxide, acetic acid, or lactic acid, that prevents bacterial growth.
  • Probiotics appear to be immunomodulators,  stimulating lymphocyte and macrophage activity, reducing markers of intestinal inflammation such as tumor necrosis factor and alpha-1-antitrypsin. They can increase the secretion of immunoglobulin A in the gut against harmful bacteria.
  • Probiotics not only fight intestinal and urogenital pathogens, but they also are helpful for several conditions such as inflammatory bowel disease,  food allergy, pouchitis,  and as an adjuvant to vaccination.
  • Remember to use only proven blends of probiotics. Not all brands of probiotics are equivalent, even if they have the same agents in them!
  • Primary uses of Probiotics include uses for Antibiotic-associated diarrhea, Clostridium dificile infections, irritable bowel syndrome, and preventing respiratory infections.
  • The use of a probiotic with antibiotics can reduce diarrhea by 45 % or so.  Lactobacillus has the best evidence for success, with  Florajen ( Lactobacillus acidophilus) being very effective. Lactobacillus plantarum299v (ProViva) is also useful.
  • Bifidobacteriuminfantus and Bifidobacterium longus are effective as is Saccharomyces boulardii for reducing antibiotic-associated diarrhea.
  • Combination products such as Lactobacillus acidophilus LA-5 plus Bifidobacterium BB12 (AB-Yogurt), Bifidobacterium lactis plus Streptococcus thermophilus (Nan 2), and  Lactobacillus bulgaricus plus Streptococcus thermophilus plus Lactobacillus casei DN114401 (DanActive, Actimel) are also effective, reducing diarrhea by 40%.
  • Probiotics are also helpful for reducing the risk of Clostridium difficile infection in patients taking antibiotics. The combination of Lactobacillus acidophilus CL1285 plus Lactobacillus casei (Bio-K+Cl1285 is effective in reducing C. dificile infection when taking antibiotics by over 80 %.
  • Lactobacillus planarium299v (ProViva) can reduce recurrence of C. dificile infections. Saccaromyces boulardii(Florastor) also can reduce C. dificile infections by over 60%.
  • Combination products include Bifidobacterium breve, Bifidobacterium longum, Bifidobacterium infantis, Lactobacillus acidophilus, Lactobacillus plantarum, Lactobacillus paracasei, Lactobacillus bulgaricus, and Streptococcus thermophilus (VSL#3) and DanActive/Actimel (Lactobacillus bulgaricus plusStreptococcus thermophilus plus Lactobacillus casei)
  • For irritable Bowel syndrome, Bifidobacterium infantis 35624 (Align or Bifantis Procter & Gamble) works well, decreasing abdominal complaints. The product, VSL#3, works well in decreasing IBS symptoms.
  • Probiotics also decrease respiratory infections by 30 % or more. Lactobacillus plantarum, Bifidobacterium longum, Bifidobacterium bifidum, Lactobacillus gasseri, and Streptococcus thermophilus are helpful in various combinations.
  • Avoid or be careful with probiotics if you are immunocompromised. Ask your doctor first before using them in that case.

Products you can use include:

  • Activia yogurt (Dannon –Bifidobacterium lactis), Align (Proctor and Gamble -Bifidobacterium infantis) for digestive health and antibiotic induced diarrhea.
  • Culturelle (ConAgra Foods – Lactobacillus GG) with multiple varieties,  It helps with digestion and decreases bloating sensation.
  • Danactive, with a mixture of probiotics in it, for antibiotic associated diarrhea.
  • Fllorajen (Lactobacillus acidophilus) with many varieties, useful for antibiotic-associated diarrhea and bowel health.
  • VSL#3(Sigma-Tau Pharmaceuticals – Lactobacillus acidophilus, L. plantarum, L. paracasei, L. bulgaricus, Bifidobacterium breve, B. infantis, B. longum, and Streptococcus thermophilus mixture) useful in inflammatory bbowel disorders and puchitis.
  • Fem-dophilus- Lactobacillus rhamnosus, for urinary health, preventing bacterial vaginosis and promoting vaginal health.
  • Probabclac and Lactinex are other agents used as probiotics with efficacy.  <—Activia probiotic  <—Culturelle  <– Danactive <–Probalac probiotic  < –Jamieson probiotic sticks  <–Florastor probiotics   <—vsl#3 probiotic

Insane Medicine – Grapes and raisins

  • Raisins have three times the antioxidants of red and green grapes. Six ounces of grapes makes and ounce of raisins, but the drying process destroys the resveratrol ( an antioxidant) , so raisins have little of this. Raisins have a little less Vitamin C.
  • Golden raisins are higher in antioxidants becuase they are preserved by added sulfites during the drying process. Beware if you have a sulfite allergy.
  • Raisins have a lot of fiber, potassium, and iron, but a cup of raisins has 440 calories, while a cup of grapes has 100 calories. Beware of the extra calories in the raisins!

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