Week of 8/3/2020

/Week of 8/3/2020
Week of 8/3/2020 2020-08-12T21:29:55+00:00

August 05, 2020

Clinical Housekeeping 

We Want to Hear From You!
Hey Wise Patients! Feedback is how we grow and develop. It let’s us adjust our care and shape our practice for the better and that starts with you. In next week’s issue, we’ll be sending out a link to a brief survey that will give us exceptional insight into how to improve our patient satisfaction, quality of care, and our clinic comprehensively. Be on the lookout for it!

Appointment Scheduling
At this time, online scheduling has been reactivated. Feel free to schedule in-person appointments, telehealth/virtual appointments or even blood draws as you see fit. If you find that navigating Athena is too challenging or you prefer hearing the voices of our health coaches, feel free to give us a call and schedule


Caffeine Fiends

For the full experience, grab yourself a cup of coffee or tea and play this song while you read. https://www.youtube.com/watch?v=4bUqpG4v7fE

A lot of people have been very interested in learning about the effects of coffee and caffeine on health.  In the United States, it is estimated that 85% of adults consume caffeine daily. The July 23rd 2020 edition of the New England Journal of Medicine published a review article “Coffee, Caffeine, and Health”* citing 95 sources ranging from “Normal caffeine consumption: influence on thermogenesis and daily energy expenditure in lean and post-obese human volunteers” and “Coffee consumption and serum lipids: a meta-analysis of randomized controlled clinical trials” to “Coffee, tea and caffeine intake and the risk of non-melanoma skin cancer: a review of the literature and meta-analysis” and “systematic review with meta- analysis: coffee consumption and the risk of gallstone disease”.  Spoiler alert: there are mostly upsides to your health with moderate caffeine and coffee consumption (except during pregnancy), but the details are interesting.

Most adults in the US ingest caffeine in coffee.  Interestingly, some of the health impacts (positive and negative) related to coffee have been attributed to the non-caffeine components.  It turns out there are hundreds of other biologically active phytochemicals in coffee, some of which are created during roasting and some of which can be filtered out depending on how coffee is prepared.  Below is a summary of the major findings of the authors of this review article with some extra attention to some of the particularly interesting findings.  It is important to note, as the authors did, that many studies of the health effects of caffeine and coffee run the risk of confounding factors that are difficult to control for and measurement error when consumption is self-reported.  Many of the studies are observational.  So while there is an abundance of research that has been done, the quality of the evidence is not always strong.

How does coffee impact cancer risk?
Studies suggest that coffee and/or caffeine consumption may decrease cancer risk. The evidence is strongest for risk reduction in hepatocellular carcinoma.  In this case, consumption of 3 cups of caffeinated (but not decaf) coffee is associated with a 60% relative risk when compared to 0 cups of coffee.  The evidence for risk reduction in endometrial cancer suggests an 85% relative risk when comparing coffee intake versus no coffee intake.  It did not show a difference between caffeinated versus decaf, or between high versus low consumption.

Studies have also suggested a possible small reduction in risk of melanoma, non-melanoma skin cancer, breast cancer and prostate cancer. (The risk reduction is seen at 2 – 21/2 cups per day and is barely statistically significant).

How does coffee impact the cardiovascular system?
Blood pressure: Most people who have experienced the effects of caffeine can understand why there has been concern that caffeine can raise blood pressure.  What the authors found when reviewing the evidence is that in people who do not habitually ingest caffeine, caffeine intake can raise epinephrine levels and therefore raise blood pressure in the short term. However, in studies that looked at pure caffeine (not coffee), most people develop tolerance in about a week.  (Individual responses can differ, and some people may not develop tolerance to the same level – more on that later).  Interestingly, studies that looked at coffee consumption (rather than pure caffeine) did not show an increase in blood pressure with coffee consumption even in patients with baseline hypertension.  One idea was that there are other components of coffee (remember those hundreds of biologically active phytochemicals) like chlorogenic acid that counteract the blood-pressure-raising impact of caffeine.

Cholesterol: This is interesting.  Speaking of biologically active phytochemicals, cafestol is one of these and it appears to increase serum cholesterol.  It is found in highest amounts in coffee that is prepared without filtering such as Turkish coffee, coffee made with a French press or Scandinavian boiled coffee.  It is found in negligible amounts in coffee made with a percolator, filter or instant coffee, and in intermediate levels in espresso or coffee made in a Moka pot.  IN randomized trials, high consumption (6 cups per day) of unfiltered coffee (with the highest amounts of cafestol) raised LDL cholesterol by 17.8 mg per deciliter when compared with filtered coffee.  In contrast, there was no increase in serum cholesterol notes with filtered coffee.

Atrial Fibrillation/CAD: Although it is easy to see how a caffeine jolt might fuel a-fib or lead to increased stress on the heart, there appears to be no association between coffee consumption and Afib, or coronary artery disease or stroke. This seems to be true for the general population as well as patients at higher risk due to baseline hypertension, diabetes or known cardiovascular disease. In fact, some studies have suggested a protective effect of coffee for cardiovascular disease, with the lowest risk group being those who drink 3-5 cups of coffee per day.

How does coffee impact weight management, Insulin resistance and Type 2 DM?
The basic science of how caffeine impacts metabolism is complicated and suggests changes in basal metabolic rate (one study showed 6 doses of 100mg of caffeine lead to a 5% increase in 24 hour energy expenditure) and changes in insulin sensitivity (especially in the liver) which may be different over the short and long term play a role.  In addition, there seems to be an effect of the non-caffeine components of coffee on glucose metabolism in the liver.  What cohort studies of the effects of habitual coffee consumption show is a reduced risk for developing type 2 DM with a dose-response relationship.

How do coffee and caffeine impact the brain?
Parkinson’s disease: Prospective cohort studies have shown a protective effect of caffeine on developing Parkinson’s disease. This appears to be an effect of caffeine and not other components of coffee because it is not seen in decaf coffee.  This has also been seen in animal models, where caffeine is shown to Prevent Parkinson’s.

Alzheimer’s: There has not been a consistent relationship noted between Alzheimers and coffee consumption.

Headache/Pain treatment: Caffeine can help with pain relief when added to common analgesics. There were 19 studies that looked at adding 100 – 130mg of caffeine to an analgesic (like acetaminophen) and found that adding the caffeine increased the proportion of people with adequate pain relief.

How does coffee impact hydration?
Anyone who drinks coffee has probably experienced its effects on sleep (it keeps you awake) and hydration (it makes you pee), but how are these found to impact health in the long term?  The authors found that while caffeine intake can stimulate urine output, no detrimental effects on hydration status were found with long term intake of moderate amounts of coffee.

How does coffee impact sleep and anxiety?
This can be very variable between individuals.  Most people know someone who can drink a shot of espresso and then go to sleep, or someone who cannot drink Earl Grey past noon without being kept awake until midnight. It’s not all in their head. It’s likely all in how they metabolize caffeine.  Studies demonstrate large variations in the rate of metabolism of caffeine and variations in the adenosine receptor gene which plays a role in the action of caffeine.  Due to these differences, blood levels can peak anywhere from 15 minutes to 2 hours after ingestion and the half-life can be anywhere from 2.5 to 4.5 hours.  Smoking also greatly accelerates caffeine metabolism, reducing the half life by 50%.  People who are sensitive to caffeine likely metabolize it differently than those who are not and are more susceptible to experiencing the side effects of anxiety and insomnia.

Too much of a good thing?
With the recent popularity of caffeine containing drinks like Red Bull, we have seen an increase in the toxic effects of caffeine.  The review indicates that toxic effects generally occur with caffeine intake of 1.2g or higher.  Doses >10g have been seen to be fatal.  This means it would be hard to overdose on coffee or tea (it would take 75-100 standard cups of coffee) to reach these levels.  But be aware of energy drinks and supplements that contain caffeine.  Women who are pregnant should also be aware of safe levels of consumption.  HIgher caffeine intake has been shown to be associated with lower birth weight babies and a higher risk of pregnancy loss.  Limiting caffeine intake in pregnancy to a maximum of 200mg per day.

Overall, moderate coffee intake (3-5 cups per day) is unlikely to cause deleterious health effects unless you are sensitive to it and it causes insomnia and anxiety, and it likely will provide health benefits by reducing the risk of several chronic diseases.  With regard to the impact on your lipid profile, you may consider trading in your French Press for a #2 Miletta filter with a pour through cone.  (If you didn’t listen to the song, listen to it now).

*van Dam RM, Hu FB, Willett WC. Coffee, caffeine, and health. N Engl J Med 2020;383:369-78. DOI: 10.1056/NEJMra1816604


Abundant, Rapid, Point-of-Care Testing for COVID19 – WHEN?

While a vaccine will ultimately end the pandemic, a cheap, abundant, point-of-care test for COVID19 is critically needed while we wait. You already know about point of care testing. It’s what we use for strep, the flu, mono, blood sugar, and many others. It can be a quick swab, or a finger prick (no ‘brain biopsy’ type swabs!). With rapid, cheap point-of-care testing for COVID, we could test frontline workers, college students, teachers, and bus drivers, for example, every single day. We could test the rest of us every few days. The point is, we could test a LOT, and FREQUENTLY. And then know who is asymptomatic but positive and therefore quarantine people before they spread it. There are currently at least 16 companies with tests either available or in development. The FDA has provided an EUA (emergency use authorization) for several already, like this one from Quidel in San Diego.

One valid concern with these tests, which look for virus proteins, rather than using nucleic acid amplification (as in PCR testing), is that they are not as sensitive/accurate and therefore could miss some positive cases. The Quidel test, for example, is stated to be 96.7% as sensitive as the PCR test. The PCR test itself is not 100% so you start to lose confidence quickly. HOWEVER, if you were able to test people every day, or every other day, the likelihood of missing a positive case diminishes quickly and everybody wins.

Sounds great – why don’t we have this test at Wise Patient yet? Yeah, trust us, we WANT it. The problem is the demand right now exceeds the supply and we are small fish compared to governments and large hospital groups. It also requires not just the test kits, but a proprietary, expensive machine to run the tests on – for now. We are planning to obtain and offer a point of care test as soon as it is feasible for us, and we will definitely announce it to you when that happens!