Arthritis and Heart Disease

Contributed by John A Rumberger, PhD, MD, FACC

Patients with rheumatoid arthritis, psoriatic arthritis, or psoriasis are at an increased risk of major adverse cardiovascular events when compared with the general population, according to findings from a large cohort study.

All three diseases had statistically similar risks for major adverse cardiovascular events (MACE) after adjustment for age, gender, and traditional CV risk factors as recently reported (Ann. Rheum. Dis. 2014 Oct. 30)

The risk of any cardiac related event was higher in patients with PsA not prescribed a DMARD (hazard ratio, 1.24; 95% confidence interval, 1.03-1.49). This risk was elevated in RA patients both with DMARD prescriptions (HR, 1.58; 95% CI, 1.46-1.70) and without (HR, 1.39; 95% CI, 1.28-1.50). Patients with severe psoriasis who were prescribed a DMARD had an HR of 1.42 (95% CI, 1.17-1.73), whereas psoriasis patients not prescribed a DMARD had an HR of 1.08 (95% CI, 1.02-1.15).The investigators used data from the Health Improvement Network, a U.K. primary care medical record database, and compared the number of cardiac related events (myocardial infarction, stroke, and sudden cardiac death) that occurred during a mean 5 years of follow-up in 41,752 patients with rheumatoid arthritis (RA), 8,706 with psoriatic arthritis (PsA), 138,424 with psoriasis, and 81,573 age and gender matched controls – who did not have any of these conditions. There was significant interaction between disease-modifying anti-rheumatic [anti-inflammatory] drug (DMARD) use and disease group (P < .001 for MACE and two components, CV death and stroke; and P = .01 for MI).

The results highlight a need for improved screening and management of traditional CV risk factors in patients with inflammatory diseases, the researchers said.

Study limitations included not being able to measure disease severity or the use of over-the-counter NSAIDs, as well as having few records on biologic medications and possibly missing DMARD prescriptions.

John A Rumberger, PhD, MD, FACC comments:

This observational study is yet another indicator that patients with a variety of auto-immune diseases are at increased risk for heart and vascular related events.  Prior studies have noted the increased risk of vascular disease not only as above with rheumatoid arthritis [not to be confused with degenerative ‘wear and tear’ arthritis] and psoriatic arthritis but also Lupus, Scleroderma, and a variety of inflammatory bowel diseases [such as Crohn’s Disease and Ulcerative Colitis].

The underlying factors for the development of heart and vascular plaque in the coronary arteries, the carotid arteries, and the aorta is inflammation mitigated by genetics as well as the interplay of these genetics with other factors such as obesity, smoking, and abnormal cholesterol.  The same is true for the variety of auto-immune diseases that increase inflammation throughout the body and are treated with a variety of anti-inflammatory medications.  Indeed better control of these auto-immune diseases will likely result in further lowering of the overall cardiovascular risks.

My own observations from our clients at The Princeton Longevity Center indicate generally earlier and more diffuse atherosclerotic plaque formation in those with long standing auto-immune disorders, as evidenced from the heart and vascular CT scans.  In such individuals an aggressive program aimed at those ‘modifiable’ cardiovascular risk factors is necessary.

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The Polypill

by John A. Rumberger, PhD, MD, FACC

There is no question that the introduction of statins into the drug armamentarium has produced untold benefits in lowering the LDL cholesterol values as well as lowering the ‘risk’ of developing heart disease.  I feel that the benefits of these medications is not just in the lowering of the LDL or ‘bad’ cholesterol but also in their powerful anti-inflammatory powers to reduce the inflammation that is part of the development of plaque in the heart and vascular arteries.

Additionally, medications that can lower blood pressure also reduce the potential inflammation in the arteries and the damage to the endothelium [a single cell layer separating the blood flowing in the arteries from the vessel wall].  Maintaining the integrity of the barrier is also a major benefit from reducing the potential for plaque inflammation in the arteries.

Low dose aspirin also is beneficial not as an anti-inflammatory as is known for the therapy of arthritis – but as a means to favorably lower the local platelet activity at the site of plaque ruptures in the vessels walls and reduce the incidence of complete thrombosis, the immediate cause of a heart attack or a stroke.

Years ago scientists conjectured that a Polypill, containing low dose statin, low dose antihypertensive medication, and low dose aspirin would be of benefit in lowing individual cardiovascular ‘risk’ by attenuating the above influences on the production and rupture of atherosclerotic plaque – the cause of almost all heart attacks and strokes.

Getting patients to adhere to use of statins, anti-hypertensive medications, and aspirin after a first heart attack is surprisingly low – despite the known benefits.  The Polypill [a single pill containing low doses of the above medications] has been proposed by many to help keep the recurrence of further heart/vascular complications in many patients.  It has also been proposed as an adjunct in preventing a first heart attack or stroke.

A recent analysis of such a Polypill has been reported in the Journal of the American College of Cardiology [JACC 2014:64:2071-2082] indicating this as a strategy to improve adherence after the first heart attack.  The authors concluded that the use of a single Polypill provided better adherence than taking each of these three medications as separate pills.

It is human nature to note that taking a single pill [such as a multi vitamin] once per day is more acceptable than taking three pills at various times per day.

In time the Polypill may be offered as a singular beneficial medication in heart and vascular disease.

John A. Rumberger, PhD, MD comments:

The problem here is that we have lived in an environment where the ‘low fat’ hypothesis, advocated by the American Heart Association and others for the past 30 years has resulted in more obese individuals and an increased incidence of diabetes in the populace.  The culprit has been further worsened by the introduction of high fructose corn syrup as a substitute for ‘sugar’ in many of our foods and especially in soft drinks.

We have become ‘addicted’ to sugar in the presumed benefits of lowering our ‘fat’ intake over the past many years.  The original research by Adkins and others has shown that carbohydrates are more of an issue than ‘fat’ in our diet.

The American Heart Association and others have now adopted issues of lowering ‘sugars’ in our diet – but the effect of denying this problem for so many years has resulted in many problems.

The average clinician has not been taught much about nutrition and knows little how to advise patients on exercise.  The admonition of ‘lose some weight and get more exercise’ is about as far as it goes.

We now have patients who are getting mediations for their obesity and metabolic syndromes that include use of statins and blood pressure medications.  Many of these people just need to know HOW to lose weight, what is the problem [and it is NOT fat in the diet] and how to properly exercise.

As a whole we would do better to properly counsel our patients on weight loss strategies, what is a proper diet, and how to properly exercise – that in my opinion is the proper ‘Polypill’.

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Fennel, Beet and Orange Salad with Cumin Vinaigrette

With beets now showing up more frequently on the stand at your local farmer’s market and with citrus fruits becoming more available at your local grocery store, this Fennel, Beet, and Orange Salad with a cumin vinaigrette will be the perfect side dish since it has a nice contrast of textures and flavors and is rich in folate, potassium, vitamin C, fiber, manganese, and riboflavin.

INGREDIENTS

  • 2 medium beets, roasted peeled, halved and cut in thin half-moons
  • 2 medium fennel bulbs (about 1 1/4 to 1 1/2 pounds), trimmed, quartered, cored and sliced very thin across the grain
  • 1 navel orange, peeled, pith cut away, and cut in thin rounds or sections
  • 2 tablespoons chopped fresh mint
  • 1 tablespoon chopped cilantro
  • 2 tablespoons lemon or lime juice
  • ¼teaspoon sugar
  • ½ teaspoon lightly toasted cumin seeds, crushed
  • Salt to taste
  • 1 small garlic clove, puréed (optional)
  • ¼ cup extra-virgin olive oil

PREPARATION

  1. Combine beets, fennel, orange slices or medallions, mint and cilantro in a large salad bowl.
  2. Whisk together lemon or lime juice, sugar, cumin, salt, optional garlic and olive oil. Toss with the salad and serve.
Nutritional information per serving:

134 calories; 9 grams fat; 1 gram saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fat; 0 milligrams cholesterol; 13 grams carbohydrates; 4 grams dietary fiber; 72 milligrams sodium (does not include salt to taste); 2 grams protein

Resource:  NYtimes.com

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You can’t beat a beet!

by Staci O’Connor MS, RD, CLC, CDN

The white beet was developed in the 18th century and the colonists brought the red and sugar beets to America in the 19th century.  Beets are now commercially grown in 31 states, California being the nation’s largest supplier.  Beets can range in color from dark purple to bright red, yellow, and white.   There is even a Chioggia beet which is red and white-striped and has the nickname “candy cane” beet.

Beets are a good source of folate, potassium, vitamin C, fiber, manganese, and riboflavin.  The beet greens, which are interchangeable with other mild-tasting greens like Swiss chard and spinach, are an excellent source of vitamin K, vitamin A, and vitamin C as well as a good source of manganese, potassium and riboflavin.

Beets are rich in antioxidants and may boost stamina to assist in exercising longer by improving muscle oxygenation during exercise.  Beets may also improve blood flow and may help lower blood pressure.  Beets are rich in a natural chemical called nitrates; through a chain reaction, your body will change nitrates into nitric oxide, which may help with blood flow, lower blood pressure, and may help to fight heart disease.  Beets also contain an antioxidant known as alpha-lipoic acid which has been shown to lower glucose levels, increase insulin sensitivity, and prevent oxidative stress-induced changes in patients with diabetes.  Finally, beets may help fight inflammation and the high fiber content of beets prevents constipation and promotes regularity.

When purchasing beets select red or white beets that are firm with smooth skins and non-wilted leaves.  Keep in mind the smaller the beet the more tender it will be.  Smaller beets (half-inch in diameter) are good for eating raw and medium to large-sized beets (more than three inches in diameter) are best for cooking.  Cooking beets will bring out their natural sweetness, but they can also be consumed raw, peeled and grated on top of a salad and even juiced.  You can also microwave beets.  If you decide to microwave beets, rinse the beet and cut all but an inch of the stalks.  Place the beet in a deep microwave-safe dish with about an inch of water on the bottom.  Microwave the beets for 2-4 minutes.  You will know if they are done when you pierce them with a fork, try not to overcook them!  If you decide to roast them, first peel them and then slice on a cutting board that is covered with wax paper.  Place the sliced beats on a foil lined baking dish and drizzle with a little bit of olive oil.  Bake at 400 or 425 degrees F for 20-30 minutes. Stir them once or twice.  (You can also include carrots and sweet potatoes if you want to incorporate other vegetables with the beets for variety.)  Keep in mind you can also use the beet leaves as greens in a salad or you can cook them and add them to a side dish like cooked spinach.

Finally be aware that eating too many beets can turn your urine pink, which some may mistake for blood in the urine.  Also, if you get kidney stones and if you are advised to cut down on oxalates in your diet, be aware that beets are high in oxalates.

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October is National Breast Cancer Awareness Month

By Debbie Jeffery, RDN LD
About 1 in 8 women will develop breast cancer at some time in her life, and worldwide, breast cancer is the most frequently diagnosed cancer in women. While some risk factors are out of our control, like genetics and getting older, there are things that can be done to lower your breast cancer risk. The American Institute of Cancer Research estimates that staying a healthy weight and exercising can prevent 38% of US breast cancer occurrences. Below are diet and lifestyle tips to help you fight breast cancer.
• Manage your weight. Being overweight or obese increases your breast cancer risk. For women who gain weight as adults and after menopause, this is especially true. What contributes to the increased risk is that estrogen is produced in the fatty tissue. The good news is that evidence shows that weight loss can lower the risk. Reduce lifetime weight gain by limiting calories and getting regular physical activity.
• Limit alcohol. Compared to women who don’t drink at all, women who have 2 or more alcoholic beverages a day have about 1 1/2 times the risk of breast cancer. The American Cancer Society recommends no more than 1 drink daily for women. A drink is 12 ounces beer, 5 ounces wine or 1 1/2 ounces of hard liquor.
• Breastfeed for as long as possible. The protective effect is probably a result of the balance of hormones due to the breastfeeding process. In addition, when breastfeeding is stopped, the body rids the breast of many cells, some of which may have DNA damage. Breastfeeding for 2 years may reduce breast cancer risk by half.
• Increase fruit and vegetable intake. Research has found a positive correlation between a decrease in breast cancer risk and an increase in certain vitamins, such as vitamin C, A, and E. Fruits and vegetables are high in these vitamins and other antioxidants. Also because fruits and vegetables are low in calories & fat and high in fiber, they are helpful for weight control.
• Exercise regularly. Exercise is a breast-healthy habit supported by many studies. Having a regular physical activity routine can help decrease estrogen levels which can decrease risk for breast cancer.
For more information visit the National Breast Cancer Awareness Month website, NBCAM.org.

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Are Gluten-Free Foods Right for Your?

By Debbie Jeffery, RDN LD
Gluten-Free is a current nutrition “hot” topic and many are using gluten-free products without first determining if it’s a good health choice for them. We know that gluten allergies and sensitivities are real. Celiac Disease is a medical condition that needs to be treated properly and the treatment involves avoiding gluten. Likewise when those that suffer from gluten sensitivities avoid gluten, symptoms disappear. However in growing numbers, those without either of these conditions are using gluten-free products in an effort to have a “healthier” diet.
There is nothing wrong with foods that are naturally gluten-free for example fruits, vegetables, beans, brown rice, nuts and quinoa. The problem is with food products on the grocery store shelves that are labeled “gluten-free”. If you decide to go gluten-free for reasons other than celiac disease or gluten sensitivity, below are factors to consider before assuming the product is a “healthier” alternative.
1. Fiber. Many gluten-free foods are made with rice or corn flour. In the process of making these flours, much of the fiber and essential nutrients are removed. Low fiber foods can have a higher glycemic effect (meaning they raise blood sugar levels more) than whole grains. If you’re trading a traditional whole grain cereal such as oat bran for a gluten-free cereal, you could be missing out on the benefits of a high fiber meal. A serving of oat bran will provide 4-6 grams of fiber, whereas a serving of gluten-free brown rice krisp provides less than 1 gram fiber.
2. Cost. Many gluten-free foods are more expensive. Gluten-free breads and cereals can be almost twice as expensive as traditional products without providing any benefit to those without an allergy or sensitivity to gluten.
3. Calories. A food product labeled “gluten-free” does not mean it is “calorie-free”. Gluten-free food products can contribute significant calories to the diet. Gluten-free bread can be almost twice as calorie dense as traditional wheat bread. Also, many food manufacturers are taking advantage of the popularity of gluten-free products and are adding the words “Gluten-Free” to the label of foods that have always been gluten-free. Those candy chews are still candy and sugar even though they are labeled “gluten-free”. Gluten-free does not make them any healthier.
Consider the above factors when deciding which foods are best for you!

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Dumbbells vs. Kettlebells

New trends continue to pop up within the health and fitness field every day. Many times we dive in head first in order to try the newest method of weight loss and fitness classes without really knowing what the reasoning behind it is. A major trend that has individuals swinging and using momentum to lift the weight are Kettlebells.

Besides the look of a kettlebell, what is the major difference between using them versus traditional dumbbells? As stated above, one of the biggest differences is the use of momentum and multi-joint based movements to create power and strength.

Involving multiple muscle groups and core movements with a kettlebell involves both strength and cardio into your workout. The momentum and swinging moves increase your heart rate and provide a greater use of range of motion and core strength.

Kettlebells also provide different grips and imbalances, unlike the dumbbell which has an even amount of weight on each end. The kettlebell has the weight in the middle, so when you are performing certain exercises, the weight shifts and changes throughout the movement.

However, even though they are great for explosive exercises and activate multiple muscle groups with each move, they have been shown in multiple studies to produce less strength gains than traditional dumbbells. You simply cannot increase the weight of a kettlebell the way you can with dumbbells and bars.

If your goal is to increase strength, stick to mainly using dumbbells and barbells with some exercises interchanged (ie. biceps curls, bent over rows). If your goal is to burn fat, gain endurance and power and slightly increase strength, than kettlebells may be a great option for you.

Kettlebells are worth checking out, but before you do, be sure to learn the proper form to avoid injury.

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