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Friday, February 15, 2019

Does drinking diet soda raise the risk of a stroke?

I have always been accident-prone. It wasn’t unusual for me to suddenly lose my balance while walking down an even-paved path as though someone had slid a banana peel in front of me. I’d slam down hard on the ground, skinning knees and elbows. I once fell off a boardwalk on my bike into a swamp, my body casting an impressive outline in the reeds — like a cartoon character who has run through a wall. My body was often a landscape of bruises and scabs, while most of my dishes were doomed to break at some point, causing consternation among my roommates. The dishes were just some of the casualties of my clumsiness, for which I was sometimes scorned and scolded by teachers, parents, and boyfriends.

But I never connected this clumsiness to how my joints and tendons seemed as fragile as the glassware I sometimes shattered: ankles that twisted and sprained at the slightest misstep; wrists wrecked and inflamed for years from the first few attempts at downward dog during an introductory yoga class; a jaw that partially dislocated from the simple act of chewing on a tortilla chip. These incidences became less rare and more routine as time wore on, as well as more severe.
Recently, many of my patients have been asking about a ketogenic diet. Is a ketogenic diet safe? Would you recommend it? Despite the recent hype, a ketogenic diet is not something new. In medicine, we have been using it for almost 100 years to treat drug-resistant epilepsy, especially in children. In the 1970s, Dr. Atkins popularized his very-low-carbohydrate diet for weight loss that began with a very strict two-week ketogenic phase. Over the years, other fad diets incorporated a similar approach for weight loss.
What is a ketogenic (keto) diet?

In essence, it is a diet that causes the body to release ketones into the bloodstream. Most cells prefer to use blood sugar, which comes from carbohydrates, as the body’s main source of energy. In the absence of circulating blood sugar from food, we start breaking down stored fat into molecules called ketone bodies (the process is called ketosis). Once you reach ketosis, most cells will use ketone bodies to generate energy until we start eating carbohydrates again. The shift, from using circulating glucose to breaking down stored fat as a source of energy, usually happens over two to four days of eating fewer than 20 to 50 grams of carbohydrates per day. Keep in mind that this is a highly individualized process, and some people need a more restricted diet to start producing enough ketones.

Because it lacks carbohydrates, a ketogenic diet is rich in proteins and fats. It typically includes plenty of meats, eggs, processed meats, sausages, cheeses, fish, nuts, butter, oils, seeds, and fibrous vegetables. Because it is so restrictive, it is really hard to follow over the long run. Carbohydrates normally account for at least 50% of the typical American diet. One of the main criticisms of this diet is that many people tend to eat too much protein and poor-quality fats from processed foods, with very few fruits and vegetables. Patients with kidney disease need to be cautious because this diet could worsen their condition. Additionally, some patients may feel a little tired in the beginning, while some may have bad breath, nausea, vomiting, constipation, and sleep problems.
Is a ketogenic diet healthy?

We have solid evidence showing that a ketogenic diet reduces seizures in children, sometimes as effectively as medication. Because of these neuroprotective effects, questions have been raised about the possible benefits for other brain disorders such as Parkinson’s, Alzheimer’s, multiple sclerosis, sleep disorders, autism, and even brain cancer. However, there are no human studies to support recommending ketosis to treat these conditions.

Weight loss is the primary reason my patients use the ketogenic diet. Previous research shows good evidence of a faster weight loss when patients go on a ketogenic or very low carbohydrate diet compared to participants on a more traditional low-fat diet, or even a Mediterranean diet. However, that difference in weight loss seems to disappear over time.

A ketogenic diet also has been shown to improve blood sugar control for patients with type 2 diabetes, at least in the short term. There is even more controversy when we consider the effect on cholesterol levels. A few studies show some patients have increase in cholesterol levels in the beginning, only to see cholesterol fall a few months later. However, there is no long-term research analyzing its effects over time on diabetes and high cholesterol.
Key takeaways from a ketogenic diet review?

A ketogenic diet could be an interesting alternative to treat certain conditions, and may accelerate weight loss. But it is hard to follow and it can be heavy on red meat and other fatty, processed, and salty foods that are notoriously unhealthy. We also do not know much about its long-term effects, probably because it’s so hard to stick with that people can’t eat this way for a long time. It is also important to remember that “yo-yo diets” that lead to rapid weight loss fluctuation are associated with increased mortality. Instead of engaging in the next popular diet that would last only a few weeks to months (for most people that includes a ketogenic diet), try to embrace change that is sustainable over the long term. A balanced, unprocessed diet, rich in very colorful fruits and vegetables, lean meats, fish, whole grains, nuts, seeds, olive oil, and lots of water seems to have the best evidence for a long, healthier, vibrant life.

About six years ago, after helping a then-boyfriend move a couch up the three stories to our apartment, I could not get out of bed for a solid week. The discs in my back simply gave out, like a box of jelly donuts someone sat on. I remember my ex telling me even his mother could have accomplished such a simple task without injury, but I could not. This kind of disapproval about my body and its idiosyncrasies now lends itself to automatic distancing on my part. If I meet someone who is critical about my physical shortcomings, I expect to not speak with them again.
Clues to the reason for my clumsiness

In more recent years, my body was besieged by an incessant, widespread, bone-deep aching pain. In particular, my sacrum and hips felt as if they had been infused with bits of broken glass that ground against me as I walked and rubbed my soft tissue raw with too much sitting. Imaging results revealed a large labral tear in my left hip, and a spine riddled with busted disks and cysts swollen with spinal fluid. Physical therapists always asked what accident I’d had or which aggressive sports I partook in to sustain so many injuries, but I could only shrug and say there was no reason I could ascertain, that life was simply taking its toll on me — albeit a heavier one that it seemed to be taking on most others, and at an earlier age than many experience.
The mystery solved

This is why it was enormous validation when I finally visited a geneticist earlier this year, who revealed after a thorough two-hour evaluation that I had Type III of a rare connective tissue disorder known as Ehlers-Danlos syndrome, or EDS. EDS is characterized by hypermobile joints and a deficiency in collagen (connective tissue) that results in pain and repeated injury. Not only does this diagnosis account for my clumsiness and much of the bodily damage I have accrued over the years, it also helps explain some of my migraines and the frequent rashes on my skin, the trouble I have regulating my body temperature, and my bowel and bladder problems.

While I was relieved at the diagnosis, I was also resentful. I have been pestering doctors for the past few years about my chronic and often disabling pain. My geneticist told me that it often takes an average of 10 to 20 years to receive a diagnosis of EDS, with many people not receiving an accurate diagnosis until well into their 40s. As with many medical conditions, EDS disproportionately impacts women. This may account for the delay in getting a proper diagnosis and treatment, as studies have repeatedly shown the medical community is not as educated on — and therefore much more likely to misdiagnose and disregard — health issues that impact women. My geneticist told me many of the women she had diagnosed had at some point attempted suicide to achieve an end to their suffering, both the physical suffering from the disorder and the emotional suffering of having their pain ignored and even questioned for years or decades.

Now that I do finally have a proper diagnosis, I have taken the initiative needed to better manage the disorder and its symptoms, including avoiding certain activities and implementing aids to stabilize and protect my joints.

As EDS is not a widely understood or known disease, my greatest hope is that my experience can offer a guide to other patients who suspect that there is more than meets the eye when it comes to their chronic pain. I also want to spread awareness among the medical community, not only about EDS, but also that just because a diagnosis is not easily apparent, does not mean there isn’t one. Doctors owe their patients their curiosity and support, because the consequences for those patients left behind can be severe. Decades of research show that yoga can reduce the emotional and physical fatigue brought on by cancer treatment. Now researchers have shown for the first time that’s also true specifically for men being treated for prostate cancer. Men who took a yoga class twice a week during treatment reported less fatigue, fewer sexual side effects, and better urinary functioning than men who did not, according a new study. “The data are convincing,” said the study’s principal investigator, Dr. Neha Vapiwala, an associate professor of radiation oncology at the University of Pennsylvania School of Medicine in Philadelphia. “What we need now is a better understanding of how and why yoga produces these benefits.”

Vapiwala and her colleagues enrolled 50 men with early or advanced non-metastatic prostate cancer who ranged in age from 53 to 85. Among them, 22 were assigned to the yoga group and the rest were not. All the men got scheduled radiation treatments during the study, 29 were also on hormonal therapy, and 19 had previously been treated surgically for prostate cancer. The groups were evenly balanced with respect to cancer treatments, in addition to other possible treatments for erectile and urinary problems. Men who already practiced yoga or were treated previously with radiation were ineligible for the study, as were men with metastatic prostate cancer.
No experience needed

The type of yoga assessed in the study, called Eischens yoga, focuses on holding and maintaining poses. “And it’s accessible for all body types and experience levels and allows for hands-on guidance from instructors,” Vapiwala said.  The sessions lasted 75 minutes each and incorporated sitting, standing, and reclining positions matched to each man’s needs and abilities. Before, during, and after the nine-week study, men in both the yoga and control groups were asked to rate their fatigue, sexual health (including but not limited to erectile functioning), and urinary symptoms.

Men in the yoga group reported improving or stabilizing symptom scores over time, whereas men in the non-yoga group reported worsening symptoms. “Ordinarily, you’d expect symptom scores to decline with continuing treatment,” Vapiwala said. “But in the yoga group, the changes were notably positive.”

Vapiwala speculates that yoga improves erectile and urinary function by strengthening core muscles and improving blood flow. Asked how she’d counsel a man who’s considering yoga during cancer treatment, Vapiwala said, “Regardless of how you view your own fitness, it’s important to keep an open mind. There’s something to be said for finding the right group and the right instructor. But you might be surprised at what you can do!”  For diet soda fans, recent news reports linking these popular drinks to higher risk of stroke may have been alarming. A closer look at the study behind the headlines suggests there’s no need to panic. But beverages naturally low in calories are probably a healthier option than artificially sweetened drinks.

The study included 2,888 people ages 45 and older from the long-running Framingham Heart Study, all of whom filled out diet questionnaires up to three times over a seven-year period. People who said they drank at least one artificially sweetened soda a day were about twice as likely to have a stroke over the following decade when compared to those who drank less than one a week. Drinking regular, sugar-sweetened sodas or beverages did not appear to raise stroke risk.

However, these types of studies can’t prove cause and effect, only an association. Also, only 97 people (3%) had strokes during the follow-up, which means only two or three of those strokes could possibly be attributed to drinking diet soda, says Dr. Kathryn Rexrode, an associate professor of medicine at Harvard-affiliated Brigham and Women’s Hospital who co-authored an earlier, larger study looking at soda consumption and stroke risk.
Stroke risk from all sodas?

That study detected a slightly higher risk of stroke in people who drank more than one soda per day, regardless of whether it contained sugar or an artificial sweetener. Although the latest study didn’t detect a higher stroke risk from sugary beverages, that certainly doesn’t suggest they are a better choice than diet sodas. Many studies have already shown that drinking sugary beverages on a regular basis can lead to weight gain, diabetes, high blood pressure, heart disease, and stroke, she notes.
Possible explanations

In fact, one possible explanation why sugary beverages weren’t linked to stroke in the recent study might be a phenomenon known as survival bias. In this case, that would mean that people who drank a lot of sugar-sweetened beverages may have died earlier from other illnesses such as heart disease.

Conversely, diet beverages may have shown a link to stroke because of a different issue, called reverse causation. In an attempt to be healthier, people who are overweight or have diabetes may be more likely to choose diet drinks over sugary ones. Their heightened stroke risk may result from their health problems rather than their beverage choice. “We might just be measuring the residual impact of obesity and diabetes,” says Dr. Rexrode.
Artificial sweeteners: Other shortcomings

Another conundrum: researchers don’t have any plausible explanation for why artificial sweeteners might increase stroke risk. Still, there may be other reasons to ditch them.

If you use artificial sweeteners to control your weight, you should know that the support for that strategy is pretty shaky. Some evidence suggests that artificial sweeteners make people crave sugary, high-calorie foods, thereby negating the sweetener’s potential to cut your overall calorie intake. And some experts believe that people who use these high-intensity sweeteners (which are hundreds of times sweeter than sugar) may come to find naturally sweet foods, such as fruit, less appealing and less-sweet foods, such as vegetables, downright unpalatable. If so, those people might be missing out on the many heart-protecting nutrients found in fresh, natural foods.

But Dr. Rexrode isn’t a stickler when it comes to diet soda. “I encourage my patients to eliminate regular soda and other sugar-sweetened drinks to avoid empty calories,” she says. “But if someone says they can’t do without a Coke in the morning to wake up, I’ll encourage them to switch to coffee or diet Coke.” Water is an even better choice, however. “There are a lot of ways to make it more appealing, both visually and taste-wise.” she adds. Try flavoring flat or sparkling water with a splash of fruit juice, or add frozen fruit, cucumber, or crushed mint.

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