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Saturday, April 27, 2019

Do “energy boosters” work?

Move over, apples: A handful of nuts a day keeps the doctor away—and might help you live longer, according to new results from two long-running Harvard studies.

“We found that people who ate nuts every day lived longer, healthier lives than people who didn’t eat nuts,” said study co-author Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. The report, in tomorrow’s New England Journal of Medicine, showed that daily nut-eaters were less likely to die of cancer, heart disease, and respiratory disease. Overall, the daily nut-eaters were 20% less likely to have died during the course of the study than those who avoided nuts. (Peanuts, which are actually legumes, counted as nuts in this study).

The findings were gleaned from nearly 120,000 participants in the Nurses’ Health Study and the Physician’s Health Study. All answered questions about their diets at the beginning of the studies in the 1980s and then every two to four years during 30 years of follow-up. The researchers classified the participants into six categories that ranged from never eating nuts to eating them seven or more times per week. The more often people ate nuts, the lower their risk of premature death.

The findings echo those of earlier studies, according to Dr. Penny Kris-Etherton, professor of medicine at the University of Pennsylvania, who highlighted nut research at this week’s American Heart Association meeting in Dallas, Texas. “Eating nuts lowers LDL (“bad” cholesterol), raises HDL (“good” cholesterol) and also lowers blood pressure and blood pressure responses to stress,” said Dr. Kris-Etherton. Her research also shows that nut consumption helps boost a process called reverse cholesterol transport, by which HDL particles in the blood sweep away fatty plaque from clogged arteries. The Harvard researchers pointed out that the composition of nuts—fiber, healthy fats, vitamins, minerals, and phytochemicals—may provide “cardioprotective, anticarcinogenic, antiinflammatory, and antioxidant properties.”

Worried that eating nuts might make you fat, since they’re high in fat? In fact, frequent nut eaters were less likely to gain weigh in this and other studies. “Nuts are high in protein and fiber, which delays absorption and decreases hunger,” said Dr. Hu, adding that nuts contain mostly unsaturated healthy fats.
No “perfect” nut

Are certain nuts better than others? “Everybody is searching for the perfect nut,” says Dr. Kris-Etherton. But the health benefits hold true for a variety of nuts, including walnuts, almonds, peanuts, and pistachios, so eat your favorite. Or, as Kris-Etherton recommends, try mixed nuts—and be sure to choose unsalted over salted. She offered the following tips for making nuts part of your regular diet:

    spread nut butter on your morning toast instead of butter or cream cheese
    sprinkle chopped nuts on cereal or yogurt
    toss nuts into a salad or stir-fry
    top fruit or crackers with nut butter
    try nut-encrusted fish or chicken, such as pecan-encrusted trout
In many ways, women are different from men. One way in which they are alike is how they “feel” a heart attack: with similar kinds of chest pain. Other heart attack symptoms may differ, but chest pain is pretty standard, according to a large new study from Europe.

This study focused on nearly 2,500 men and women being evaluated in one of seven emergency departments for a possible heart attack. In such a situation, doctors typically ask a few standard questions about chest pain. For this study, the researchers asked 34 detailed questions about chest pain or discomfort, such as:

    When did it start?
    How long did it last?
    Where specifically in the chest do you feel the pain?
    How large is the spot where you have pain?
    Does the pain extend into any other part of the body – the neck, throat, back, one arm, both arms, etc.?
    What does the pain feel like (pressure, stabbing, burning)?
    Does the pain get worse with a deep breath, cough, sneeze, or movement?

No differences in chest pain were seen between men and women except for two characteristics. Pain that lasted two to 30 minutes and decreased in intensity reduced the chance that the symptoms were caused by a heart attack in women. This was not true for men—the pain of a heart attack could be of short duration. And women with heart attacks tended to have longer lasting pain, 30 minutes or greater, compared to men. The results were published yesterday in JAMA Internal Medicine.

The kind or duration of chest pain didn’t help tell a heart attack from some other problem. The conclusion? A careful medical history, an electrocardiogram, and blood tests are the best way to diagnose a heart attack in men and women.
Recognizing a heart attack

During a heart attack, more than three-quarters of men and women experience chest pain or discomfort. In the run-up to a heart attack, chest pain with exertion is a more common warning sign in men, while women often have other types of symptoms.

Surveys of women who have had heart attacks have shown that up to 95% said they noticed something “wasn’t right” in the month or so before their attacks. Two of these early warning symptoms, fatigue and disturbed sleep, were especially prominent. Some women, for example, said they were so tired they couldn’t make a bed without resting. Women who do feel something unusual in the chest often describe the sensation as discomfort, aching, tightness, or pressure rather than as pain.

Some heart attacks are unmistakable. Others aren’t easy to detect because the symptoms are subtle or masquerade as something else. The faster a heart attack is diagnosed and treated, the greater the likelihood it won’t cause long-lasting damage. If you feel any of the symptoms below, or see them in someone you are with, call 911 or your local emergency number right away:

    pain or discomfort in the center of the chest
    pressure, aching, or tightness in the center of the chest
    pain or discomfort that spreads to the upper body, especially the shoulders, back, arms, neck, throat, or jaw
    unusual sweating
    sudden dizziness
    unusual shortness of breath
    unusual fatigue or weakness
    unexplained nausea or vomiting
It’s been a topsy-turvy few days in the world of heart health and disease. Last week the American Heart Association and American College of Cardiology released new guidelines that upended previous recommendations for who should take a cholesterol-lowering statin. A few days later, two Harvard physicians challenged the accuracy of the calculator included in the guidelines, saying it would cause many people to unnecessarily take a statin. The story made headlines in The New York Times and prompted a closed-door review by the guidelines committee.

The controversy over the calculator should serve to improve this useful tool. I just hope it doesn’t make people mistrust the guidelines, which I think will help prevent more heart attacks, strokes, and premature deaths than the earlier ones.
How the new guidelines change things

The previous guidelines recommended that individuals take a statin if the level of their harmful LDL cholesterol was above a certain number. The guidelines also recommended that many people get their LDL level down to 70 milligrams per deciliter (mg/dL), even if that meant taking a statin plus other medications, a strategy never proven to prevent heart attack or stroke.

The new guidelines no longer focus on “the numbers,” but instead focus on the risk of heart disease or stroke risk. Taking a statin is now recommended for:

    anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related condition
    anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 mg/dL)
    anyone with diabetes between the ages of 40 and 75 years
    anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

The calculator included in the guidelines aims to gauge an individual’s chances of developing atherosclerotic cardiovascular disease (ASCVD) over the next 10 years. ASCVD includes arteriosclerotic heart disease (heart attack, stroke, the chest pain known as angina, or severely narrowed coronary arteries), peripheral artery disease, and stroke or transient ischemic attack. The calculator uses nine pieces of information—sex, age, race, total cholesterol, HDL cholesterol, systolic blood pressure, current treatment for high blood pressure, diagnosis of diabetes, smoking habit—to do this. The new guidelines recommend a statin for seemingly healthy people with a risk of 7.5% or higher.

RiskCalculator

Cardiologist Paul Ridker and epidemiologist Nancy Cook, both at Harvard Medical School, say that the calculator likely overestimates ASCVD risk for many people. Such overestimation would mean that millions of otherwise healthy people would take a statin long term with no health benefit, but the real possibility of experiencing harmful side effects.
Deciding who needs a statin

The controversy over the calculator doesn’t affect anyone in categories 1, 2, or 3 above. For them, a significant amount of research has shown that the benefits of taking a statin far outweigh the risks. It does affect those who haven’t yet developed any visible forms of ASCVD.

For example, what if your is LDL high, say 150 mg/dL, and the calculator says you have an 8% risk of developing ASCVD in the next 10 years. The new guidelines say “take a statin.” But guidelines are just that—information to guide a decision, not to mandate it. The best approach for such individuals is to have a discussion with a trusted physician.

Some of my patients in this situation would prefer not to start taking a medication. I would counsel them to try a healthier eating pattern like a Mediterranean-style diet and exercise more. Lifestyle changes should always be a priority—even if a statin is needed. Others will prefer to start taking a statin, and I would go along with that decision.

One of the things the new guidelines have clarified is which statin to use. There are seven on the market: atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The guidelines say that the ones with the best evidence for preventing heart attack and stroke are simvastatin, atorvastatin, and rosuvastatin.

Down the road, genetic testing may help better gauge an individual’s ASCVD risk and refine which statin would work best. Until then, the new guidelines represent a step forward for prevention. Stroll the aisles of any pharmacy or “health food” store and you’ll see a multitude of herbs and other supplements that claim to boost energy. Soft drinks and so-called energy drinks include these products. Yet there is little or no scientific evidence to support the claims for most of these substances. The fact is, the only thing that’ll reliably boost your energy is caffeine or other stimulant—and their effects wear off within hours.

Here’s a look at some of the substances that are commonly touted as energy boosters.

Chromium picolinate. This trace mineral is widely marketed to build muscle, burn fat, and increase energy and athletic performance, but research has not supported these claims.

Coenzyme Q10. This enzyme is found in mitochondria, the energy factories of our cells. Coenzyme Q10 supplements have been shown to improve exercise capacity in people with heart disease, and may do the same in people with rare diseases that affect the mitochondria. In other cases, the effects are not clear. One small European study suggested that people with chronic fatigue syndrome might benefit from supplementation with coenzyme Q10, but more research is needed.

Creatine. The body makes own creatine; it is largely found in muscle. But it is widely sold as a supplement. There is some evidence that taking creatine can build muscle mass and improve athletic performance requiring short bursts of muscle activity (like sprinting). But there is little evidence it can do the same in older adults, or that it can reduce a feeling of fatigue in anyone.

DHEA. Sometimes marketed as a “fountain of youth,” dehydroepiandrosterone (DHEA) is touted to boost energy as well as prevent cancer, heart disease, and infectious disease, among other things. The truth is that this naturally occurring hormone has no proven benefits and some potentially serious health risks. Some research shows that DHEA can damage the liver. It can also lower levels of beneficial HDL cholesterol. And because this hormone is related to estrogen and testosterone, there is concern that it may increase the risk for breast and prostate cancers. By increasing levels of testosterone, it can also encourage acne and facial hair growth in women. Until further research clarifies the side effects, it’s wise to avoid taking DHEA.

Ephedra. Although ephedra was banned by the FDA in 2004 because of major safety concerns, including increased risk of heart attack and stroke, it remains available for sale on the Internet. Any effectiveness that ephedra may have in terms of boosting energy probably results from two substances it contains—ephedrine and pseudoephedrine—which may increase alertness. There is no safe amount of ephedra you can consume. If you want to boost your energy by stimulating your central nervous system, a cup of coffee or another caffeinated beverage will work just as well.

Ginkgo biloba. Derived from the maidenhair tree, ginkgo biloba has been used for centuries in Chinese medicine and is now a common dietary supplement in Western countries. Its effects on cognition (thinking), mood, alertness, and memory have been the subject of many studies, but many of those studies have not been of high quality. A Cochrane Collaboration review found the evidence was too weak to conclude that ginkgo biloba improved cognition in people with Alzheimer’s disease. Regarding memory in people without dementia, the evidence is contradictory. Some studies suggest that ginkgo biloba may improve some aspects of mood, including alertness and calmness, in healthy subjects. By making you more alert and calm, it may increase your sense of energy.

Ginseng. This relatively safe and popular herb is said to reduce fatigue and enhance stamina and endurance. It is sometimes called an “adaptogen,” meaning it helps the body cope with mental and physical stress and can boost energy without causing a crash the way sugar does. Data from human studies are sparse and conflicting. Some studies report that ginseng improves mood, energy, and physical and intellectual performance. Other research concludes it doesn’t improve oxygen use or aerobic performance, or influence how quickly you bounce back after exercising.

Guarana. This herb induces a feeling of energy because it’s a natural source of caffeine. But consuming a lot of guarana, especially if you also drink coffee and other caffeinated beverages, could ultimately lower your energy by interfering with sleep.

Vitamin B12. Some doctors give injections of vitamin B12 as “energy boosters.” But unless they are given to correct anemia that results from a true deficiency of the vitamin, there is little evidence that vitamin B12 treatments boost energy.

Instead of relying on a supplement for energy, I recommend switching to a healthful diet—more vegetables, fruits, whole grains, nuts, lean protein, and unsaturated fats—and exercising more. That’s truly a better way to beat an energy shortage, and it’s one your whole body will appreciate.

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