Asthma – ease the wheeze

Asthma – ease the wheeze

This time of the year, i start seeing more patients with poorly controlled asthma – probably due to the cold winter setting in.

Invariably, i have patients and worried parents trying to get to the bottom of their asthma attack, and what had caused the asthma in the first place. It is a very difficult question to answer sometimes, especially when there are many anecdotal reports documented on Google.

It is true that Asthma risk can be higher if mothers consume certain foods while pregnant. But that does not imply that every Asthma trigger should be engaged when a woman is pregnant. In fact, data from more than 60 000 pregnancies was evaluated specifically looking at the consumption of fish and any resultant protective effect on Childhood Asthma. The results showed that there was no evidence of a protective association of fish and seafood consumption during pregnancy with symptoms of  asthma and allergic rhinitis in offspring.

Asthma control in children has serious implications for other areas of health. There were 2 studies recently published that evaluated difficult to control asthma in children, with levels of overweight and obesity. The first study showed  a significant association between severe persistent difficult-to-control asthma and obesity and the second study showed that many children with persistent asthma are overweight or obese, have limited opportunity for activity, and experience activity limitations. It is therefore important to assess asthma management in children with a view to weight management as well – children with asthma should have a plan to keep active when their asthma is well managed.

For patients whose asthma is controlled and who have a low risk for future  exacerbation, current guidelines recommend gradually stepping down treatment to identify the lowest dose needed to maintain control. A recent article showed that adding Immunotherapy at this stage will assist in managing asthma in patients who are classified as moderate asthmatics. A bit more research is needed here – but it provides some hope when it comes to down-titrating asthma medication.

Remember to assess asthma every 6 months with Spirometry measurements – its the best way to ensure control, in my opinion.

Read some of my previous articles on Asthma here (asthma updates, assessment of asthma, aerobic exercise and asthma). Please feel free to comment or share this if you feel that it may benefit others.

Dr Essack Mitha

Breakfast – the most important meal of the day

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It is surprising to see how many people skip breakfast these days. Reasons vary from not having time in the mornings, to skipping a meal altogether to aid weight loss. Well, there have been some interesting studies published recently that emphasise why breakfast should not be missed. We also look at some of the regular “breakfast items” that we consume.

There have been a few studies going around in the last few years, investigating the cognitive benefits of breakfast. A recent article did an analysis of these studies, and found that healthy adults that consume breakfast displayed a small but robust improvement in cognition, specifically memory. Another study published in the Journal of Behavioural Medicine investigated a group of people that had enrolled in an Obesity Treatment program. Data confirmed that those who had breakfast, and also decreased the number of meals consumed in the day had a better weight loss outcome (compared to those that skipped breakfast and decreased daily meal frequency).

Ok, so we have confirmed that breakfast is important – but what should we be having? My favourite is always a cup of coffee…and its justified by an article in Clinical Nutrition, that found that patients who had 1-2 cups of coffee per day had a decreased incidence of cognitive dysfunction. As I write this, I am having my second cup…

While we are at it, another article in the European Journal of Nutrition found that the regular consumption of green/roasted coffee blends have positive effects on blood pressure, glucose and triglyceride levels. The authors suggest that this could be a recommendation to lower the risk of metabolic syndrome in healthy adults. I have also previously written about coffee – Caffeine consumption reduces risk of erectile dysfunction and Coffee – the healthy drink!

For those of you who enjoy your coffee, and add in some low-cal sweeteners instead of regular sugar – read this! A recent study evaluated adults who used low-cal sweeteners for a long period of time (mean 10 years), comparing them to non-users. They found that the users of low-cal sweeteners had an increased BMI (0,8kg/m2), a 2,6cm larger waist circumference and a 53% higher incidence of abdominal obesity. These findings are quite alarming, and results were adjusted for age, sex, race, dietary intake, physical activity and diabetes.

The authors quite correctly summarised the research by saying “These findings underscore that weight management strategies should be rooted in understanding how the human body responds to certain types of food instead of merely considering the theoretical caloric content.”

Lets end up this piece with a review of research on dairy consumption that was published in Annals of Epidemiology. The authors evaluated results from 17studies on total dairy products, and 16 studies on milk, specifically looking at the risk of obesity. The authors concluded that the risk of obesity decreased by 16% for every 200g/day increment of milk consumption.

That’s all for now – I would like to finish that cup before it gets too cold! Please feel free to comment or share this if you feel that it may benefit others.

Dr Essack Mitha

High blood pressure – making sense of the noise

This week, I examined a few newly diagnosed hypertension patients, who expressed frustration at the conflicting information on the net, specifically with diets that should be followed – whats good for you, what prevents high blood pressure, etc.

The problem with browsing the net is that many opinions are published without scientific proof. I always advise my patients to first check if the article is talking about anecdotal evidence, or scientific evidence.

When it comes to food products and hypertension, we can see a few published articles that can give us some direction. This will also guide you on how to recognise quality articles.

A recent article showed that the use of Whey protein for 8 weeks lowered ambulatory blood pressure and other risk factors for cardio-vascular disease (Whey protein decreases blood pressure). Another article investigated the effects of daily dairy consumption in Chinese adults (Dairy food intake decreases the risk of hypertension)- over 37 000 adults where investigated over many years, and the authors concluded that the amount of dairy consumed had an inverse relationship with the risk of high blood pressure. The final food related article I have investigated a group of Taiwanese adults, and found that vegetarians had a 34% reduced risk of developing hypertension when compared to non-vegetarians (Vegetarian diet reduces the risk of hypertension).

I want to conclude the article review with a mention of exercise on blood pressure. GA Kelly evaluated over 700 adult woman and found that aerobic exercise reduced systolic and diastolic resting blood pressures (Aerobic exercise and blood pressure) – it reminds me of 2 of my previous posts – Dancing your high blood pressure away, and Tai Chi – its effects on blood pressure, weight and quality of life.

That’s all for now. Please feel free to comment or share this if you feel that it may benefit others.

Dr Essack Mitha

E-Cigarette safety – Up in Smoke?!?

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So this week, while going through the many medical updates and research articles in my inbox, I had the misfortune of seeing 2 articles published on the same topic, with 2 completely different conclusions.

The first article, published in Annals of Internal Medicine, looked at the long term safety findings of E-cigarettes (E-Cigarettes: Long term safety findings). The article made me look twice, I must admit. An extract is below:

Conclusion:

Former smokers with long-term e-cigarette–only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette–only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.

The first thing that struck me was that the author compared groups of smokers of cigarettes against smokers of e-cigarettes. There is no duration of study, or number of participants included in the abstract. This begs the question of scientific validity. While I have reviewed only the abstract, I would have preferred to see a comparison of e-cigarette users compared to non-smokers, to determine long term safety. I would rather compare e-cigarettes to NO cigarettes.

The second article was published in JAMA Cardiology, looked at the cardiovascular risk associated with e-cigarette users against non-users (Thank you!!). The sample size was small (42 patients), but the author chose to look at specific risk factors of cardiovascular stress. Their conclusion:

Conclusions and Relevance  In this study, habitual e-cigarette use was associated with a shift in cardiac autonomic balance toward sympathetic predominance and increased oxidative stress, both associated with increased cardiovascular risk.

You can also view my previous e-cigarette articles here – E-Cigarettes negatively effect attempts to quit smoking, and E-Cigarettes and Alcohol use.

I have a few patients that claim that e-cigarettes help to give up smoking. I always tell them that there is still nicotine in e-cigarettes, and it may not be too long before they need to give up e-cigarettes too. For those wishing to quit, read about this innovative method Cigarette Crushing App helps you kick the habit.

Thank you for stopping by. Please feel free to comment or share this if you feel that it may benefit others.

Dr Essack Mitha

 

Diabetes – why is it so difficult to manage?

I have seen many patients over the last few years, who have been on treatment for diabetes at various health centres, with uncontrolled glucose levels. The patients sometimes did not even have yearly HbA1C measurements done, and management was usually only based on a fasting plasma glucose.

The more serious anecdotal finding, was that approximately 10% of these patients had some form of renal dysfunction, and they did not even suspect it.

Besides the usual investigations that should be done, patients in South Africa tend to leave decision making entirely to the health care provider. I always try to educate my patients on the causes, investigation and management of diabetes. Usually, this goes a long way in making patients more complaint with medication and management of their conditions.

We also need to look at other factors that make management of diabetes more difficult. A study published in The Lancet in November 2016 looked at the prevalence of Diabetes in Sub-Saharan Africa (Diabetes prevalence in Sub-Saharan Africa) . It found the median prevalence of diabetes was 5% and the median prevalence of overweight or obesity was 27%. With values so high, it was very encouraging to note that the South African government was considering imposing a sugar tax (see my previous post A tax on sugar)-as expected, the soft drink manufacturers were quick to try and prove no correlation between their drinks sugar content and the diseases it is accused of causing. However, an article published in September 2016 by Al Saint Jacques clearly shows a direct link between the consumption of fructose and the onset of diabetes.

Another way to improve management is to have less invasive and easier to use medications. Ask any diabetic of the most distressing part of treatment, and most will speak about injecting themselves with Insulin. Well, a newly developed delivery method called Cholestosome may make it possible too have a really effective oral Insulin pill (I discussed another oral insulin pill here An easy pill to swallow?). Watch out for this one – it may be a few years away, but t will definitely have an impact.

Thank you for stopping by. Please feel free to comment or share this if you feel that it may benefit others.

Dr Essack Mitha

Gout – a pain in the…toe!

We are fast approaching the summer holidays – and that means lots of braais, barbecues and alcohol for lots of people. Unfortunately, for those with Gout, this is a time of serious gout flares.

Lets look at some of the latest guidelines for treatment of Gout.

Firstly, there has always been some controversy about starting urate lowering therapy (like Allopurionol) during a Gout flare. A recent study published in Rheumatology International in November 2016, looked at the effects of urate lowering therapy (ULT) on duration of pain in a gout flare. The meta-analysis of 537 studies showed that the initiation of urate lowering therapy during an acute attack did NOT increase pain severity or lead to early ULT discontinuation.

There has been a relatively new medication registered for add on therapy in Gout treatment – Lesinurad. We have been fortunate to conduct some of these Lesinurad studies at our site – and our patients were really impressed.

Lesinurad is a novel compound that decreases serum uric acid through the inhibition of urate transporters in the kidney. The studies that we conducted, included the addition of Lesinurad to background Allopurinol therapy in patients with Gout and with serum Uric Acid > 6,5 mg/dL (published in Arthritis and Rheumatism, November 2016). The results showed that the addition of Lesinurad to Allopurinol was statistically superior that Allopurinol alone in reducing serum Uric Acid levels to normal values. It was also well tolerated by patient. It is interesting though, that there was no statistically significant difference between the 2 groups in the number of acute gout flares experienced.

It still remains a very good option for patients who require further intervention to decrease uric acid levels.

Dr Mitha

Asthma -interesting updates

We have a large number of patients that report to us with Asthma, sometimes only when their Asthma is poorly controlled. Our team members spend quite a bit of time in educating patients about the basics of Asthma, and where relevant, some of the more recent advances related to Asthma management.

We focus today, on 2 interesting papers published earlier this year. The first relates to Asthma patients who are on treatment for Diabetes, and the second relates to the use of antibiotics in children with Asthma-like symptoms.

An article was published in Respirology, in July 20165, where the author evaluated Asthmatic patients using concurrent Diabetes treatment. An eleven year retrospective cohort study was done, where 1332 patients with Diabetes and Asthma were identified. Each patient was followed up for a 3 year period, and they were separated into 2 groups – one group used Metformin for their Diabetes, and the other group did not.

Metformin users had a clinically significant lower risk of Asthma-related hospital admissions and Asthma exacerbations. This is worth bearing in mind for patients who have Asthma as well as Diabetes.

The next article was published in The Lancet, in January 2016, and looked at the management of Asthma-like symptoms in children between 1 and 3 years of age. Between 2010 and 2014, the author evaluated 158 episodes of Asthma-like symptoms, with 72 patients receiving Azithromycin and 79 patients receiving placebo. It was found that a mean duration of episode was 3,4 days in patients who received Azithromycin, and 7,7 days in those who received placebo.

We do know that bacteria and viruses are frequently associated with Asthma-like symptoms in children, the article suggests that Azithromycin should be routinely used in children who present with exacerbations.

These two articles have a direct impact on the way we manage patients with these indications.

Dr Mitha