February Newsletter
In This Issue
Small Changes = Big Results
Think With Your Gut
Antioxidants and Chemotherapy
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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Welcome to the February newsletter. The goal of this newsletter is to prove information and analysis of timely topics from recent articles published in the medical literature. I hope you find this information useful and helpful in your health journey.  
Losing weight is near the top of most people's "to do" list. When I ask my patients if they consider themselves the appropriate weight, most say no. Many of us are trying to lose at least a few pounds or at a minimum trying to maintain where we are. What are the characteristics of people who successfully lose weight and then maintain their weight loss? What strategies do they use? What works? The first article looked at almost 4800 people who successfully lost at least 20 lbs and kept it off for at least 1 year. Their secrets? Check out the first article.

We are learning more and more about the gut-brain and gut-overall health relationship all the time. We have identified certain species of bacteria that are associated with reduced inflammation, cognitive health and less frailty as we age. Lower levels of these "healthy" bacteria lead to more problems as we age. How can we maintain or regain a healthy GI microbial system? The second article has a way.

Treatment of cancer is traumatic. Chemotherapy, radiation therapy and targeted therapies are designed to kill cancer cells, but they can also have effects on healthy cells. Many people try different vitamins, antioxidants, and supplements in an effort to combat these side-effects. But is this the right thing to do? Instead of making us better, could these vitamins and supplements increase our risk of recurrence and even death? The answer may surprise you. 

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Small Changes = Big Results
Use of multiple small strategies is key to weight loss and weight maintenance
This large study was designed to compare individuals who successfully lost weight and maintained their weight loss to those who were unsuccessful with weight loss to discern which specific strategies or habits are beneficial. The subjects were from the Weight Watchers Success Registry who were successful in long term (>1 year) maintenance of substantial weight loss (> 20 lbs). This group was compared to a control group of obese, weight stable people. The successful weight loss maintainers practiced more healthy dietary choices, self-monitoring, and psychological coping. They also reported greater habit strength for healthy eating, which was related to longer duration of maintenance and less perceived effort for maintenance of their healthy habits. 
  • Objective:  The study's purpose was to use validated questionnaires to identify novel behavioral and psychological strategies among weight loss maintainers (WLMs) in a commercial weight management program
  • Methods:  Participants were 4,786 WLMs in WW (formerly Weight Watchers, New York, New York) who had maintained weight loss >/=9.1 kg (24.7 kg/23.8% weight loss on average) for 3.3 years and had a current mean BMI of 27.6 kg/m 2 . A control group of 528 weight-stable individuals with obesity had a mean BMI of 38.9 kg/m 2  and weight change <2.3 kg over the previous 5 years.
  • Results:  WLMs versus Controls practiced more frequent healthy dietary choices (3.3 vs. 1.9; =0.37),  self-monitoring (2.6 vs. 0.7; =0.30),  and psychological coping (2.5 vs. 1.1; =0.25) s trategies. WLMs also reported more willingness to ignore food cravings (4.4 vs. 3.5; =0.16)  and had greater habit strength for healthy eating (5.3 vs. 3.2; =0.21).  Standard canonical coefficients indicated that dietary (0.52), self-monitoring (0.40), and psychological (0.14) strategies as well as habit strength for healthy eating (0.15) contributed independently and most (49.5% of variance) to discriminating groups.
  • Conclusions: In a widely available weight management program, more frequent practice of healthy dietary, self-monitoring, and psychological coping strategies as well as development of greater habit strength for healthy eating differentiated long-term WLMs from weight-stable individuals with obesity.  
This study is quite well done and offers some excellent strategies for all of us to use whether we are actively trying to lose weight or just maintain our weight. Almost 4800 individuals who successfully lost at least 20 lbs and kept the weight off for over 1 year were studied and compared to a group of obese individuals who had not lost weight. The successful people tended to use a variety of self-monitoring and psychological coping strategies and developed stronger habits toward healthy eating. "Habit strength in healthy eating emerged as a defining characteristic among WLMs, (weight loss maintainers) suggesting greater frequency, repetition, and automaticity in healthy eating choices." 

Some of the key strategies used included:
  • Setting daily food intake goals
  • Keeping healthy foods in visible locations and more accessible 
  • Recording daily food intake
  • Measuring foods
  • Thinking about past successes/minimize negative thoughts 
  • Remaining positive in the face of weight regain 
These strategies fit with what I have seen in my patients who have made successful lifestyle changes. People who are successful make healthy decisions and form good health habits. These new habits then make it easier to make good decisions. This habit strength is the key to success. The study found that people who maintained their weight for the longest time reported the greatest habit strength. The stronger their habits, the less effort they took to maintain, and more success followed. Another key point is showing greater self-kindness. Everyone makes mistakes. We all fall off the wagon occasionally. Many people beat themselves up when they stumble. The successful people remained positive and could draw upon past successes to get back on track. 

There is so much information and misinformation around today about nutrition and weight loss. Despite all the arguments about carbs, calories and keto, it appears there isn't one thing that results in success. It's several of little things done frequently. Start with one thing and build from there. The hardest part is starting. Find one thing you can do to improve and do it. The longer you do that one thing, the easier it will become. 

Think With Your Gut
Increased gut bacteria linked to less frailty and improved cognition

As people age, bodily systems tend to deteriorate and higher levels of inflammation are noted. This leads to increased frailty and cognitive decline. There have also been changes noted in the types of GI bacteria present in the body. The researchers in this study wanted to see if changing the dominant types of GI bacteria present after following a Mediterranean style diet would be associated with improved function and less frailty. 

They found that the Mediterranean diet is associated with increased abundance of specific types of bacteria in the GI system which have been linked to lower fragility, improved cognitive function and lower inflammation.

  • Objective: Ageing is accompanied by deterioration of multiple bodily functions and inflammation, which collectively contribute to frailty. We and others have shown that frailty co-varies with alterations in the gut microbiota in a manner accelerated by consumption of a restricted diversity diet. The Mediterranean diet (MedDiet) is associated with health. In the NU-AGE project, we investigated if a 1-year MedDiet intervention could alter the gut microbiota and reduce frailty.
  • Design: We profiled the gut microbiota in 612 non-frail or pre-frail subjects across five European countries (UK, France, Netherlands, Italy and Poland) before and after the administration of a 12-month long MedDiet intervention tailored to elderly subjects (NU-AGE diet).
  • Results: Adherence to the diet was associated with specific microbiome alterations. Taxa enriched by adherence to the diet were positively associated with several markers of lower frailty and improved cognitive function, and negatively associated with inflammatory markers including C-reactive protein and interleukin-17. Analysis of the inferred microbial metabolite profiles indicated that the diet-modulated microbiome change was associated with an increase in short/branch chained fatty acid production and lower production of secondary bile acids, p-cresols, ethanol and carbon dioxide. Microbiome ecosystem network analysis showed that the bacterial taxa that responded positively to the MedDiet intervention occupy keystone interaction positions, whereas frailty-associated taxa are peripheral in the networks.
  • Conclusion: Collectively, our findings support the feasibility of improving the habitual diet to modulate the gut microbiota which in turn has the potential to promote healthier ageing.

This article found  that increased adherence to the Mediterranean Diet modulates specific components of the gut microbiota that are associated with a reduction in risk of frailty, improved cognitive function and reduced inflammatory status. What was really interesting is the observation that there was consistency of associations between the diet-modulated microbiome markers with biological markers of ageing (independent of nationality - this was a 5 country study). They found that the microbiomes of healthy individuals are similar and the unhealthy individuals are each aberrant in their own way. The thought is that by protecting the 'core' of the gut microbial community, adherence to the Mediterranean diet could facilitate the retention of a stable community state in the microbiome, resulting in resilience and protection from changes that are found in unhealthy people which result in increased frailty, cognitive decline and inflammation.

The relationship of the gut microbiome and health is in the early stages of our understanding and is likely influenced by several factors. There is no reason to think that the benefits seen in this study are not applicable to people of all ages so we should all strive for a stable community of GI bacteria to potentially reduce the adverse effects of aging. There may also come a time that we will be able to "transfer" these healthy bacteria to people to prevent some of the problems of aging. But until then, we should look to our diet for health.

Although he lived some 2400 years ago, Hippocrates said " Natural forces within us are the true healers of disease". The more we learn, the more we realize that he was correct. 

Antioxidants and Chemotherapy
Taking antioxidants during chemotherapy resulted in higher risk of breast cancer recurrence 
Chemotherapy is very hard on the body. Many people are looking for ways to help cope with this stress and the harsh effects it can have. Taking antioxidants is supposed to help the body get rid of free radicals which are known to be harmful. Therefore, taking them during chemotherapy could be beneficial. This study collected data on antioxidant and supplement use during chemotherapy for breast cancer. This data is part of a larger study comparing chemotherapy regimens. The antioxidants studied were vitamins A, C, E, carotenoids, and coenzyme Q-10. They also evaluated users of multivitamins, iron and vitamin B12. Contrary to what we may think, the researchers found that the antioxidant users before and during treatment had a 40% higher risk of recurrence and death. This was not seen in the users of multivitamins so the dose of antioxidant is likely important with higher dosages necessary to see this effect. Vitamin B12 and iron use during this time period was also associated with significant increase of recurrence and additionally vitamin B12 use was associated with increased risk of death. 

  • PURPOSE: Despite reported widespread use of dietary supplements during cancer treatment, few empirical data with regard to their safety or efficacy exist. Because of concerns that some supplements, particularly antioxidants, could reduce the cytotoxicity of chemotherapy, we conducted a prospective study ancillary to a therapeutic trial to evaluate associations between supplement use and breast cancer outcomes.
  • METHODS: Patients with breast cancer randomly assigned to an intergroup metronomic trial of cyclophosphamide, doxorubicin, and paclitaxel were queried on their use of supplements at registration and during treatment (n =1,134). Cox proportional hazards regression adjusting for clinical and lifestyle variables was used. Recurrence and survival were indexed at 6 months after enrollment using a landmark approach.
  • RESULTS: There were indications that use of any antioxidant supplement (vitamins A, C, and E; carotenoids; coenzyme Q10) both before and during treatment was associated with an increased hazard of recurrence (adjusted hazard ratio [adjHR], 1.41; 95% CI, 0.98 to 2.04; P = .06) and, to a lesser extent, death (adjHR, 1.40; 95% CI, 0.90 to 2.18; P = .14). Relationships with individual antioxidants were weaker perhaps because of small numbers. For nonantioxidants, vitamin B12 use both before and during chemotherapy was significantly associated with poorer disease-free survival (adjHR, 1.83; 95% CI, 1.15 to 2.92; P < .01) and overall survival (adjHR, 2.04; 95% CI, 1.22 to 3.40; P < .01). Use of iron during chemotherapy was significantly associated with recurrence (adjHR, 1.79; 95% CI, 1.20 to 2.67; P < .01) as was use both before and during treatment (adjHR, 1.91; 95% CI, 0.98 to 3.70; P = .06). Results were similar for overall survival. Multivitamin use was not associated with survival outcomes.
  • CONCLUSION: Associations between survival outcomes and use of antioxidant and other dietary supplements both before and during chemotherapy are consistent with recommendations for caution among patients when considering the use of supplements, other than a multivitamin, during chemotherapy.
During times of illness we often think that vitamins or supplements can be helpful, and sometimes they are. However, this study points out the dangers of assuming that supplements and vitamins are always helpful or just benign. We generally feel that antioxidants are good for us. After all, they keep free radical atoms from grabbing electrons from our healthy cells which  causes DNA damage. Antioxidants give out electrons to the free radicals thus protecting our healthy cells. However, the goal of radiation therapy, chemotherapy, and other targeted therapies is to kill cancer cells by generating free radicals around the cancer cells. The free radicals grab electrons from the cancer cells causing cancer cell destruction. If we are taking larger doses of antioxidants, these antioxidants will give electrons to the free radicals as they normally do, but now this is protecting the cancer cells because the free radicals are no longer stealing electrons from the cancer cells and causing their destruction. Iron may cause more recurrences because iron plays a role in tumor initiation and progression through effects on the tumor micro-environment. It isn't clear why vitamin B12 is associated with increased recurrence. 

While this study looked at breast cancer treatment in particular, it certainly makes sense to proceed with caution in taking antioxidants, iron or vitamin B12 regardless of the type of cancer being treated. The antioxidants may protect the normal cells from the effects of cancer treatments, but at the same time they are also protecting the cancer cells which can lead to higher rates of recurrence. 

Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. Feel free to pass this on to anyone you think would benefit from this information. 

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As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email , phone, or just stop by! 

To Your Good Health,
Mark Niedfeldt, M.D.