Monthly Archives: June 2018

Will Stress Lead to Autoimmune Disease?

A worrisome report from a group of Icelandic scientists linking stress to autoimmune disorders appeared in a recent edition of JAMA. The media alerted us to their findings in terms that were, well, stressful: If, or more realistically when, we experience severe stress, we will be increasing the likelihood of developing diseases ranging from thyroid to hair-loss disorders. This report resonated with me, as I did develop an autoimmune skin disorder at an age when it was rare to show the first symptoms.

My physician asked whether I had been stressed earlier in the year. The answer was yes. My stress was due to worry and sorrow over a close friend’s diagnosis of a terminal disease. Would I have been “immune” from this autoimmune skin problem if the year had been less stressful? The media description of the results of the study would have you believe it to be so. An acquaintance told me about her son who is working an impossible number of hours as a first-year associate in a large law firm. “He is so stressed,” she told me, “that I am worried he will develop some awful disease.” And she quoted from a news release about the study to me:

The study looked through medical records of more than 100,000 Swedish adults who had been diagnosed with stress-related psychiatric disorders, the medical records of 126,652 siblings of these patients and 1.1 million unrelated individuals. The two latter groups had no stress-related disorders. Forty percent of those with stress-related psychiatric disorders were male and their average age, 41.

What is striking about their results is that over a 10-year follow-up period, a significantly larger number of individuals who had a stress-related psychiatric disorder were diagnosed with an autoimmune disease compared to the other two groups. Some of the diseases included Addison’s disease, rheumatoid arthritis, psoriasis, multiple sclerosis (M.S.), Crohn’s and celiac disease. Also, the risk for developing a particular disease differed. For example, there was a higher risk for celiac disease than rheumatoid arthritis.

Does this mean that a stress-filled year or short-lived acute stress will lead to a lifetime struggle with an autoimmune disease such as M.S.? The answer is no. To begin with, the stress is not simply stress; it is a diagnosed psychiatric disorder. Post-traumatic stress disorder, acute stress reaction, and adjustment disorders are listed by the authors as associated with increased risk for subsequent autoimmune disease.  Being stuck in a two-hour traffic jam on the way home from work is very stressful but unlikely to cause the development of the skin lesions associated with psoriasis.

Moreover, as the authors point out (despite the hype in the media), “The relatively modest differences in the incidence rates of autoimmune disease between the exposed and unexposed,” (i.e. stressed and non-stress disordered individuals) “…should not lead to special monitoring of people who have been diagnosed with a stress disorder.”

But this conclusion still leaves the question as to why there should be a connection, even a weak one, between PTSD and M.S. or thyroid disease. Changes in cortisol levels, changes in pro-inflammatory cytokine levels, or an overly active inflammatory response/immune system are put forth to attempt to understand the process leading to the disease. But no workable answer is available yet.

What is so sad about the study results, however, is that those who have a stress-related disorder, such as PTSD, which in itself significantly affects quality of life, might then have to endure many decades of another disease that compounds the diminished quality of life.  However, the report found that antidepressant treatment for PTSD reduced the risk of an autoimmune disease. Thus treating the stress disorder may be the answer to preventing another lifetime disorder from developing.

“Association of Stress-Related Disorders With Subsequent Autoimmune Disease,” Song, H., Fang, F., Tomasson, G., et al, JAMA 2018; 319:2388-2319

Losing Your Sense of Smell to Lose Weight

A friend who went through an intense treatment of chemotherapy two years ago is still unable to smell, and thereby taste, most foods. She was warned this might be a treatment side effect, and when it would disappear was unknowable.  She used to eat chocolate, any kind of chocolate, as long as it was chocolate. “I don’t eat chocolate anymore,” she told me. “It tastes funny.”

That chocolate tastes funny to her is more likely to be from a loss of a sense of smell than taste.  According to Nancy E. Rawson, Ph.D. who is on the staff at the Monell Chemical Senses Center, Philadelphia, and Scientific Advisor to the Anosmia Foundation, it is our sense of smell, our olfactory system that gives us our taste sensitivity.  When people loss this olfactory function, when they have anosmia, they may not be able to taste the difference between an orange and a piece of chocolate.

As she and others explain, our ability to taste is almost totally dependent on our ability to smell. Of course, we can detect the basic tastes: sweet, salty, sour, bitter and umami, a savory taste sometimes associated with the taste of protein, even if we lose our sense of smell. But smell is the conduit to taste; without it the tastes of most foods are unrecognizable. We have cells high inside the nose, the olfactory sensory neurons, that connect directly to the brain. When we smell coffee brewing or popcorn popping, the microscopic “odor” molecules released by the food stimulate these neurons, and they message the brain, which then identifies the odor for us. (Dogs are much better at this than humans.) Interestingly, the smells come in not only through our nose, but also through a neuronal path connecting the roof of the throat to the nose. So when we chew our food, odors are also released that are picked up by the olfactory sensory neurons and sent to the brain.

A stuffy nose makes us aware of how important smell is in tasting what we are eating, and influences how much we enjoy or reject a particular food (think smelly cheese). But although it is frustrating to be unable to taste food when we have a cold, we know that once our stuffy nose disappears, we will be able to smell and enjoy eating once again.

It is this aspect of eating, enjoying the taste of food brought about by our ability to smell it, that has spawned interest in preventing the dieter from doing so.  If the food is tasteless, might the dieter eat less? Would the dieter stop eating when full, rather than continue to eat beyond fullness because the food tastes so good? Would impulsive eating of freshly baked chocolate chip cookies or French fries be thwarted because, without their scent, they lose their irresistible taste?

Apparently this occurred among subjects participating in a study in which they wore a nasal insert designed to redirect airflow in the nose away from those sensory olfactory neurons that tell the brain what we are smelling. Dror Dicker, MD, Rabin Medical Center, Israel, at the European Congress of Obesity a few weeks ago, described the device called Noznoz. The 65 subjects who wore the device while following a calorie-controlled diet lost significant weight; they especially reduced their consumption of sweet foods. In a sense, they had a perpetually stuffed nose.

Although the use of a custom-fitted nose device to reduce food intake is new,  the link between loss of the olfactory sense and altered food intake is well known. (“Olfactory Dysfunction Is Associated with the Intake of Macronutrients in Korean Adults,” Kong, Il, Kim, So, Kim, Min-Su et al, PLoS One 2016 ;11: 0164495)  Food intake among more than 1300 participants who had olfactory dysfunction (or inability to smell) was altered, compared to those who did not have this problem. Protein intake was reduced among males, the intake of sweet foods among young women, and consumption of high-fat food among young and middle-aged women. How the loss of the sense of smell differentially affected what was eaten or rejected was not explained in the paper.

Loss of the ability to smell odors may be one of the unwelcome aspects of aging. (“Effects of aging on smell and taste,”  Boyce, J. and Shone, G., Postgrad Med J. 2006 Apr; 82(966): 239–241)  The effect of aging on the deterioration of the sense of smell is so prevalent that one wonders if there ought to be generational-based recipes; foods made for an older population might have ingredients such as vinegar or lemon that can be tasted without a good sense of smell. Boyce and Shone state that in a recent survey almost 65% of 80-97 year olds have an impaired sense of smell.  The effects can be far ranging from the addition of too much salt and other spices to food in order to taste it, to malnutrition. Just as the loss of the sense of smell affects food intake among a younger population and decreases their food intake, so too the very old may eat less indiscriminately. They not only might avoid sweet or fat-rich foods, but food in general, thus causing them to be at risk for malnutrition. This is especially worrisome if their food intake is not sufficient to provide essential nutrients like protein, vitamins and minerals.

Fortunately the NozNoz and other interventions like a nasal spray that numbs the nose to smells, do not permanently eradicate this important sense. Indeed, its greatest utility might be putting them on when passing by sources of enticing food odors like sausages and onions cooking at a street fair that might tempt one into eating. It remains to be seen whether weight will be regained when and if the dieter removes the nose plugs. And of course, they may be helpful in cleaning up after a baby or dog.



Working Toward Weight Gain

A few days ago, I was in the office of my ophthalmologist for my annual eye exam. The practice is huge, and the volume of patients is processed–so to speak–by a row of administrative personnel, each sitting in a cubicle. I checked in at one such space and later checked out with the same clerk. As I watched her scan the computer to then print out the appropriate paperwork, it occurred to me that her job was almost totally sedentary. She did not have to move more than a few inches to access her computer, and the printer was under her desk so she did not have to walk over to another area to retrieve a printout. She was not chained to her chair, yet I doubt she was able to leave it until lunch and then again when the office closed. Unless she had far to go for lunch, or exercised during that noon break, she was completely sedentary for hours.

Until robots take over many of the routine jobs now performed by humans, more and more employees will be working in occupations characterized by an absence of physical activity. About seven years ago, a report was published on changes in physical activity related to occupation over the past fifty years in the United States. The authors used data from the United States Bureau of Labor Statistics that analyzed the amount of energy expended for jobs in private industry from l960 on. When the data were first collected in the early l960s, almost half of non-government jobs required moderate to strenuous physical activity. 50 years later, this number dropped to 20 percent. The authors translated these figures into changes in the number of calories that are expended in work and stated, “We estimated a reduction of more than 100 calories per day in occupation-related energy expenditure over the last 50 years.”

50 years ago, the woman processing my eye doctor’s records would have been using a typewriter and thus expending more energy than tapping on a computer keyboard. She probably would have to get up from her chair and walk to the office copy machine to make a copy of my record rather than pushing a button on her computer and reaching under her desk to retrieve the paper from the printer. Multiply this by every patient, every five minutes or so, and her calorie output would have been considerably more than it is today.

The authors of this report discussed the implications of the decrease in work-related physical activity as a risk factor for obesity. They suggested that as we increase the use of labor-saving, we are promoting the increase in weight of the population in general.

They recommend physical activity to compensate for the sedentary nature of many occupations. According to them, if the woman processing my paperwork engages in 150 minutes of moderate activity a week, she will compensate for her lack of activity during her work hours. But, as they point out, only one in four Americans meets this goal. Given the long commuting time many workers face, as well as the unending tasks to be done at home, it is unlikely that the three out of four Americans who are not exercising will suddenly find the time to do so during their limited after work hours. And even if some physical activity occurs on weekends, unless it is prolonged it probably will not compensate for the inert workweek.

Chairs perched on bicycle pedals and mini treadmills, are now being used by many who otherwise might be stuck unmoving an office chair. Those who fear the consequences of prolonged inactivity welcome the opportunity to move the bottom half of the body while the head and hands are occupied in writing reports or code. The use of these devices could be expanded to a much larger population such as medical office workers or anyone else forced to spend most of the workday seated. However, this is unlikely to occur; in addition to the obvious cost of such devices, it might seem strange to check into a medical office for an appointment and find the medical secretary bouncing up and down on her under-desk pedals.

Another option is to schedule walking breaks for workers who otherwise have little opportunity to stand up, let alone walk. This requires time and attention to the employee’s schedule; five-minute walking breaks when patients are waiting in line to be checked in or out means having someone available to cover while the break occurs. This may be too much trouble logistically and too costly financially. Ironically, employees who still smoke and must leave the workplace to do so have a built-in opportunity to move. If they can take a break to smoke, why shouldn’t others be allowed to take a break to move?

Another solution is to rotate the sitting employee into positions that require walking so that for some of the work day he or she is released from the chair. In the office I have referenced, another employee takes the patient to the area where the doctor’s office is located. (The practice is so large one almost needs a GPS system to find the appropriate office by oneself.) If the person checking people in and out were to be a patient escort for part of the day, or some other job that required walking, then the sedentary routine would be broken.

But these are rather weak solutions to a major problem confronting most occupations: How do all of us whose work is associated with being relatively inert get enough physical activity without sacrificing sleep, family, social obligations, and financial goals? Perhaps the answer is for workplaces to offer brief opportunities to stretch and to move, even if it is only for 15 to 20 minutes a day.

It may not be enough to compensate for all those hours of sitting, but it is a start.