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In the Loop
Issue 244 - April 22, 2020

Irritable Bowel Syndrome (IBS)

April is IBS Awareness Month. IBS is a common disorder affecting the intestine. The lifetime risk of developing IBS for a Canadian is 30 percent, according to the GI Society.

Causes
The exact cause of IBS is unknown. Researchers believe that IBS and other chronic pain syndromes develop from a reciprocal relationship between biological, psychological, and social factors. Possible factors that play a role include problems moving digested food through the small and large intestines (known as motility), how the brain interprets intestinal nerve signals, changes in the bacteria in the gut (microflora, the good bacteria may be different in people with IBS compared to healthy people), stress and anxiety. Some people may have a hypersensitive colon. HealthLink BC describes IBS as a functional disorder because the intestines do not function as they should.

Diagnosis
There is no definitive test for IBS. In order for a diagnosis to be determined, a person must meet the criteria based on symptoms. Three subtypes of IBS include IBS-C (constipation predominant), IBS-D (diarrhea predominant), and IBS-A (alternating between constipation and diarrhea).

Symptoms
Symptoms, which can fluctuate day to day, include belly pain, cramping, bloating, gas, mucous in the stools, a feeling that the bowels have not completely emptied, and changes in bowel patterns (diarrhea often with an urgency to move the bowels, constipation, or alternating between the two). Each person has a unique IBS experience within the range of known symptoms. Symptom triggers include stress, illness, specific foods, hormonal changes, or eating patterns. Different foods may cause different symptoms in individuals. The mental health impact includes feeling depressed, anxious, and embarrassed. A challenge is the unpredictable nature of the condition e.g., the urgency to go to the bathroom. HealthLink BC notes that even though there is nothing wrong with the structure of the intestines, IBS is not a psychological condition – the symptoms are real.

Some facts about IBS
  • It is not life-threatening but it is long-term. It is not related to cancer or more serious conditions
  • According to the Canadian Digestive Health Foundation, Canada’s rate of IBS is one of the highest in the world at 18 percent
  • Affects more women than men
  • It is most common in adults in their thirties and forties but can occur at any age and can resolve unexpectedly for periods throughout an individual’s lifespan, and then recur  
  • People with a family history of IBS, who have mental health conditions or a history of sexual, physical, or emotional abuse may be at higher risk for developing IBS. Estrogen (hormone)therapy before or after menopause is also a risk factor for IBS
  • Only a small number of people with IBS have severe signs and symptoms. The impact of IBS is that 70 percent of people living with IBS say that it interferes with day to day activities, while 46 percent miss work or school because of their IBS symptoms, therefore impacting productivity and work performance and interfering with social activities and relationships. One study found that people with IBS seeking treatment for their symptoms had quality of life as poor as adults living with heart disease, heart failure, and diabetes
  • Having IBC can impact a person financially due to extra costs associated with obtaining over-the-counter treatments and alternative therapies to address symptoms
When to see your doctor
The Harvard Men’s Health Watch indicates that you should see your doctor if you have constant gastrointestinal symptoms that are new, if you see blood in your stools or you are losing weight unintentionally, or if you have a family history of colon cancer or inflammatory bowel disease. 

Treatment
While the condition is long-term and does not have a “cure,” it does not get progressively worse. The goal of treatment is to manage the condition. Treatment includes changes in diet and lifestyle, avoiding foods that trigger symptoms, getting regular exercise, managing stress, and sometimes prescribed or over-the-counter medications and supplements.
  • Healthy eating guidelines - according to Harvard Men’s Health Watch, what you eat and do not eat has the biggest impact on IBS symptoms. Trigger foods to avoid or limit include chocolate, alcohol, caffeine, dairy products, fried and fatty foods, soft drinks, fruit juices, and sports drinks. Some people benefit from following what is called a “Low-FODMAP diet.” FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are short-chain carbohydrates that are poorly absorbed by the gut. Following this diet was found to be helpful for 50 to 86 percent of people with IBS, according to a meta-analysis. You may also be encouraged to keep a food diary to identify the quantities and types of foods that trigger symptoms. A Registered Dietitian can help guide you with these choices. 
  • Stress management – is the main strategy to address IBS symptoms. Activities such as yoga, meditation, and cognitive behavioural therapy (CBT) have been studied for their effectiveness and they have been found to help reduce symptoms.
  • Medications and supplements - fibre supplements and laxatives for constipation or medication to help with diarrhea may be recommended. Probiotics may help with gut health, but the results of that research have not yet been definitive. Although exactly how probiotics work in the body is not clear, they may improve IBS symptoms by changing the gut microbiota. A 2019 systematic review of probiotics for IBS found that overall, the beneficial effects were more distinct in the trials using multi-strain supplements with an intervention of 8 weeks or more, suggesting that multi-strain probiotics supplemented over a period of time have the potential to improve IBS symptoms. Here is some more information about the potential use of probiotics to help improve symptoms of IBS. If you are considering taking probiotics, either by supplements or with yogurt with live and active cultures, check with your doctor or dietitian before doing so.
A new study looks at mindfulness for IBS
Pharmacological treatments and changes in diet are not able to eliminate symptoms completely. Therefore, researchers are looking at the potential of behavioural interventions. A recent small study published in the journal Neurogastroenterology & Motility involved 53 women and 15 men with IBS. The group participated in an 8-week mindfulness-based stress reduction class. Participation in this class was associated with significant improvements in gastrointestinal symptoms, symptom-related anxiety, and quality of life. The large effects were maintained at three-months after the class. The message is that mindfulness training can result in significant improvements in quality of life and symptoms without medications and changes in diet. Senior author Kirsten Tillisch explains that acting with awareness, or moment to moment awareness in daily actions, was particularly important. This approach may work because it prevents the brain from going to old fears and worries.  

Resources
  • Canadian Digestive Health Foundation website and infographic
  • GI Society: Canadian Society of Intestinal Research website
  • Unlockfood website
  • US National Institute of Diabetes and Digestive and Kidney Diseases website 
Low-FODMAP Diet resources 
  • Canadian Digestive Health Foundation website
  • HealthLink BC - Healthy Eating Guidelines for IBS handout 
  • Harvard's Low-FODMAP Diet article
  • GI Society website
Mindfulness resources 
  • Provincial Health Services Authority Mindfulness Resources handout  
  • Mindful: Healthy Mind, Healthy Body website
  • UCLA Mindful Awareness Research Center website
  • The University of Oxford Mindfulness Centre website
Sources: Science Daily website, Canadian Digestive Health Foundation website, HealthLink BC website, Mayo Clinic website, GI Society: Canadian Society of Intestinal Research website, Unlockfood website, Harvard Men's Health Watch website
 


Being Prepared during COVID-19: Food and Supplies

Dalhousie University, in partnership with Angus Reid, conducted a cross-Canada survey on March 17 asking 1000 Canadians how they are reacting to the pandemic. At that time, a total of 41 percent of Canadians declared that they had made provisions as a result of the outbreak, while 63 percent of Canadians had provisions at home before the outbreak. People are being encouraged to only buy what they need, as the government is assuring people that grocery stores will not run out of food.

Health Canada is advising people to “stock up on essentials but avoid panic buying” during the COVID-19 pandemic. According to the Health Canada website, the reason for stocking up with non-perishable food items is so that you won’t need to go shopping if you become ill. As well, having these items on hand will ensure you don’t have to leave your home to go to the grocery store during the peak of the outbreak. Dietitians of Canada suggests buying a few extra items at every shopping trip to build up your stock, thus preventing stores from running out of items. 

What food products should I buy?
The first step is to assess what you have on hand. Here is a list of key food items to consider stocking in your pantry:

Fruit - choose fruits that last longer and that are whole as opposed to chopped or sliced fruit which won’t last as long. Some good fruit choices include:
  • Fruit purees/sauces (e.g., apple)
  • Canned fruit in water, frozen fruit, and dried fruit
  • Long-lasting fresh fruits such as apples, oranges, lemons, limes, and pomegranates
Vegetables
  • Canned vegetables such as green beans, carrots, peas, diced tomatoes, and pumpkin puree
  • Low-sodium vegetable-based soups and chilis
  • Frozen vegetables such as broccoli, cauliflower, and asparagus
  • Jarred tomato sauce and salsa
  • Long-lasting fresh vegetables such as potatoes, sweet potatoes, yams, butternut squash, spaghetti squash, beets, cabbage, spaghetti squash, carrots, parsnips, onions, garlic, and whole unsliced mushrooms
Protein
  • Canned/pouched tuna, salmon, or chicken
  • Frozen seafood such as shrimp or individual salmon pieces
  • Eggs and egg substitutes
  • Nut and seed butter
  • Unsalted nuts and seeds
  • Dry or canned beans (you can save money by soaking dried beans)  
Grains
  • Whole wheat pasta and chickpea pasta
  • Brown rice
  • Ancient grains such as quinoa and farro
  • Whole grain, whole wheat, or sprouted bread (can all be put in the freezer)
  • Oats
  • Popcorn
  • Whole wheat or seed crackers
Dairy
  • Boxed (shelf-stable) or powdered milk
  • Hard cheeses which tend to last longer such as parmesan cheese
Healthy Fats
  • Olive and avocado oil  
  • Flax seeds and chia seeds
  • Unsalted grass-fed butter (you can freeze)
Another item is boxed or canned low-sodium broths. 

What if my grocery store is out of frozen items?
The Harvard TH Chan School of Public Health has a few suggestions for items that can be frozen:
  • Vegetables - wash, chop and blanch in boiling water for one minute and then put them right away under cold running water to prevent spoilage. Then put them in an airtight container or freezer bag and label with the date. Some vegetables that freeze the best are broccoli, asparagus, green beans, Brussel sprouts, and carrots. Vegetables that are high in water content do not freeze well including cucumbers, tomatoes, and lettuces.
  • Fruits - some fruits that tend to spoil more quickly include bananas, all berries, cantaloupes, and pineapples. These can all be chopped up and put in the freezer. 
  • Other items - you can freeze bread, muffins, fish, poultry, and meat.
What about household supplies?
Toiletries - toothpaste, toothbrushes, floss, toilet paper, feminine hygiene products, incontinence supplies, diapers, shampoo, conditioner, razors, shaving cream, hand soap (you can keep liquid in shared places, but please reserve separate bars of soap for each person), hand sanitizer with a minimum of 60 percent alcohol, and moisturizer for hands.

Medications - the Government of Canada suggests having a month’s supply of prescription medications, as well as over-the-counter pain relievers, stomach remedies, cough and cold medicines including throat lozenges. Fluids that will replenish your body with electrolytes are also recommended. Additional items include tissues and a thermometer.

Household - extra laundry detergent, bleach, liquid soap, garbage bags, paper towels, and household disinfecting products. Health Canada has published a list of hard surface disinfectants that are likely to be effective for use against COVID-19. The website states, “Although they [household cleaners] do not claim to kill COVID-19, cleaners can play a role in limiting the transfer of microorganisms.” Use these products often on high-touch surfaces (such as toys, toilets, phones, electronics, door handles, bedside tables, and television remotes). You can also make a diluted bleach solution using 1 teaspoon (5 mL) per cup (250mL) if using bleach that is 5 percent sodium hypochlorite. This will make a 0.1 percent sodium hypochlorite solution.

Pets - don’t forget pet foods and supplies such as kitty litter, pet medications, etc.
 
Resources
  • The Government of Canada website has an Emergency Kit Checklist
  • The Ottawa Public Health website has a Pandemic Preparedness Checklist for Coronavirus (COVID-19)
  • The Sharethegoods website has a short checklist of the food and household items to buy if you are unsure
Here are some more of the sources we used and these links contain additional great information about food and supplies: Good Housekeeping website, The Straight website, Government of Canada website, Retail-Insider website, Huffington Post website, Harvard TH Chan School of Public Health website, Dietitians of Canada website, Dalhousie University Faculty of Agriculture report, Healthline website
 
 


Skin Care for Hands 

WebMD states that washing your hands is the “single most important piece of advice health experts can give to help us stay safe from COVID-19.” Washing your hands with soap and water or using alcohol-based hand rub kills viruses that may be on your hands. Elizabeth Scott, PhD, co-director at the Center for Hygiene and Health in Home and Community at Simmons University in Boston tells WebMD that, “In the final analysis, it’s the hands. The hands are the connecting piece.”

The skin
The outermost layer of our skin is composed of oils and wax. The skin is a shield from the outside and a guard for the skin’s natural moisture. Dermatologists at the American Academy of Dermatology (AAD) report that frequent hand washing can result in dry skin that can flake, itch, crack, and even bleed. The following are tips for keeping our hands from becoming dry:   
  • Follow the proper handwashing process - we have heard again and again that we should be frequently and thoroughly washing our hands for at least 20 seconds. This means washing the backs of our hands, the thumbs, between the fingers, and under the nails and the nail beds, as these are areas that are not washed well. According to Dr. Clayton Cowl, chair of Mayo Clinic’s Division of Preventive, Occupational, and Aerospace Medicine, people always forget to wash the thumbs. Rinse thoroughly, as this is key to washing away viruses, and remember to use the disposable towel you dried your hands on to turn off the tap and turn the door handle to exit. A Mayo Clinic Proceedings 2012 article concluded that paper towels are better than air dryers for drying hands because your hands are dried faster and more thoroughly, and contamination happens more from wet as opposed to dry hands.
  • Use warm, not hot water when washing with soap and water - hot water strips out the skin's natural oils offers no advantage over warm water, and can aggravate eczema.
  • Use mild soap - soap helps germs slip off your skin as you rub your hands together. Choose soap over hand sanitizer when possible, as most hand sanitizers have alcohol that dries out the skin. Remember too that if your hands have visible dirt or grease on them, you need to use soap and water and not alcohol-based hand sanitizer. Susan Kline, director of nursing coordination for the University of Washington Clinics, suggests selecting brands of soap with shea butter, aloe or jojoba oil, and few ingredients overall. Avoid scented soaps because the chemicals can be irritating to the skin. What about the type of soap i.e., bar, liquid, or foaming? A 2017 study cited by WebMD found that foaming pump soap did not significantly reduce bacteria, but liquid soap did. The study, however, was small and was the first of its kind, so results are preliminary. As well, participants only washed their hands for six seconds. The researchers suspect that a shorter wash time occurs with foam because it is faster to rinse wash off.  When it comes to bar soap, researchers have found that because it stays wet, the bacteria stick around, but they have not found that bacteria transfer between users. Store bar soap so it will dry out and rinse it before using it. Maureen Cividino, Infection Protection and Control (IPAC) physician with Public Health Ontario, however, tells Chatelaine magazine that bar soap should be used by one person, while liquid soap can be shared (e.g., at the sink).
  • Use hand cream on slightly damp hands - the University of California, Los Angeles (UCLA) Health says that moisturizing is a step that we tend to overlook. Frequently washing our hands and failing to use a moisturizer can lead dryness, redness, flaking, discomfort, and cracks in the skin, and can exacerbate symptoms for people with pre-existing skin conditions like eczema. Cracks in the skin can be entry points for bacteria. Dr. Jonathan Silverberg, a member of the Medical Scientific Council of the Asthma and Allergy Foundation of America (AAFA), recommends carrying a pocket tube of moisturizer. After washing your hands, apply a generous amount of moisturizer to mostly dry skin (i.e., your skin should still be a little damp), making sure to coat all surfaces of your hands and fingers. The AAD says to make sure to get the product onto the tips of your fingers, as that area can be prone to dryness and cracking. Any tubes you carry for moisturizing or for liquid soap should be cleaned so that they are not contaminated. What types of moisturizer should you choose? Dr. Julia Carroll, a dermatologist at Toronto’s Compass Dermatology and lecturer at the University of Toronto’s Faculty of Medicine, tells Global News that hand cream is better than lotion because the cream is oil-based, whereas lotion is water-based and will cause more dryness. The American Academy of Dermatology also advises using ointments and creams that come out of a tube, as opposed to a pump, because they are more effective. Choose an unscented cream with an emollient (moisturizing treatments applied directly to the skin to soothe and hydrate it.) and an occlusive (provides a barrier to prevent evaporation from the skin's surface). Emollients are ingredients like plant oils, mineral oils, and shea and cocoa butter, while lanolin, mineral oil, and silicone are examples of occlusives. Other moisturizers include humectants, like glycerin, honey, and aloe vera. If your hands are regularly cracking and bleeding, are oozing, are red and swelling, or are super dry and scaly and self-care has not addressed the problem, speak with a pharmacist or your family doctor. People with eczema should be proactive and use moisturizers to help maintain the skin barrier and prevent flare-ups of eczema. If these steps do not work, a prescription topical therapy may be needed. 
If you have dry, cracked hands, are you at risk for getting the coronavirus?
The National Eczema Association expert panel says that “we don’t really know for sure at this point. However, because the coronavirus seems to be transmitted through contact transmission with the mouth, eye, and airway mucosa – either directly or indirectly - it seems to be unlikely that damaged skin increases the risk.” A person with dry, cracked hands would be more susceptible to bacterial infections and viral infections such as Herpes Simplex Virus (HSV).

Wear gloves for protection
If it is cold out, wear gloves to keep dry air away from the skin and rubber gloves for washing dishes or using disinfectants or antiseptic wipes. For deep moisturizing, apply lotion and wear cotton or spa gloves overnight. The AAD indicates that petroleum jelly can be put on your hands before putting on gloves and going to bed. 

Warning from the AAD 
The organization asks that the public not believe everything they see or hear on social media. Some of the myths:
  • Fact - using a moisturizer after washing your hands does not negate your hand-washing efforts
  • Fact - there is no evidence that using hand sanitizer makes you more vulnerable to infections or viruses.
Resources 
  • Looking for moisturizing products - the Canadian Dermatology Association gives a “Recognized Skin Health” seal for products meeting the following criteria: low potential for irritation, fragrance-free or unscented, do not contain the most common allergens, and non-comedogenic (blocking pores). The list is available on their website
  • Reduce the Spread of COVID-19: Wash your Hands poster from the Public Health Agency of Canada
  • Dr. Cowl of the Mayo Clinic demonstrates in this video how to wash hands, clean cell phones and wipe down workstations 
  • Dr. Joe Schwarcz of McGill University talks about hand sanitizers in this video 
  • David Suzuki Foundation Queen of Green website discusses using Castile soap 
Sources: The Guardian website, University of Washington Right as Rain website, World Health Organization website, UCLA Health website, AAFA website, National Eczema Association website, WebMD website, AAD website, Mayo Clinic website, Global News website, Chatelaine website
 
 


Dairy Milk and Breast Cancer

According to the Harvard Men’s Health Watch website, “Dairy is one of the most controversial food groups. Is it healthy - or a health risk? It really depends on what you need.” Vasanti Malik, a nutrition research scientist with the Harvard TH Chan School of Public Health feels that dairy isn’t vital in a diet but it can be an easy way to get calcium, vitamin D, and protein for some people. She says that milk is not necessary for adults, but if adults choose to drink milk, they should choose low-fat milk. The new (2019) Canada Food Guide lists water as the “beverage of choice,” and has de-emphasized dairy. Low-fat white milk, however, is still included as a “healthy drink option.” The Harvard Healthy Eating Plate recommends limiting milk and dairy to one to two servings per day since high intakes are associated with increased risk of prostate cancer and possibly ovarian cancer.

When it comes to breast cancer risk and dairy products, study results have been mixed, with one meta-analysis finding an increase in breast cancer risk with higher milk consumption while other studies have found the opposite relationship. A 2018 comprehensive systematic overview of current evidence from pooled analyses/meta-analyses and systematic reviews (PMASRs) notes that the studies have been of low to moderate quality, and “to fully characterize valid associations between dairy consumption and risk of cancer and/or mortality rigorously conducted, PMASRs including only high-quality prospective study designs are required.”

A 2019 meta-analysis of 8 publications looked at milk and yogurt intake and breast cancer risk, finding that “available epidemiological evidence does not support a strong association between the consumption of milk or milk products and breast cancer risk,” but larger studies are needed worldwide to validate the relationship between dairy food intake and breast cancer.

Now, a 2020 study from researchers at the Loma Linda University Adventist Health Sciences Center, published in the International Journal of Epidemiology, has looked at the relationship between dairy products, soy, and breast cancer. This study was observational, therefore, it can only show an association and not a cause and effect relationship i.e., we cannot say with certainty that “A causes B” or “Milk causes breast cancer,” but rather that “Milk may be linked to breast cancer.”  

The study used data from 52,795 women in North America with an average age of 57 (postmenopausal) including data from Seventh Day Adventists. This group’s data is helpful because they are vegetarian and have a higher rate of drinking soy milk compared to typical North Americans. At the start of the study, none of the participants had cancer. The women filled out food-frequency questionnaires and 24-hour food recalls at the beginning of the study, along with demographic information, family history of breast cancer, physical activity, alcohol consumption, use of hormones and other medication, breast cancer screening, and reproductive and gynecological history. The participants were followed for up to 8 years. At the end of the study, 1,057 women developed breast cancer, representing two percent of the study participants. The study findings:
  • The risk of cancer in the study was 2 percent or 2 cases for every 100 women. Drinking one cup of milk increased the risk by 50 percent while drinking 2 to 3 cups increased the risk by up to 80 percent when milk drinkers were compared to non-drinkers. This is called relative risk, which measures the risk of a certain event happening in one group compared to another. The Dietitians of Canada explain the absolute risk. The risk of cancer in this study was 2 percent and 3 percent among women who drank milk. The absolute risk difference is 1 percent, so the headline stating a 50 percent increase is reporting a statistic that suggests a big risk. The organization states, "Reporting the absolute risk difference (1 percent) gives more relevant information on the actual risk for an individual." 
  • Gary Fraser, lead study author and an epidemiologist and professor at Loma Linda University School of Public Health, explains that the lifestyle risk perspective of developing breast cancer for the average woman who drinks no dairy milk is 8 to 9 percent. If a woman drinks at least two-thirds of a cup daily the lifetime risk would be 13 percent
  • The amount of fat in the milk did not appear to affect the results
  • No association was found between breast cancer risk and soy intake
  • No associations were found between breast cancer risk and cheese or yogurt
The authors conclude that higher intakes of dairy milk were associated with greater risk of breast cancer when adjusted for soy intake. They add that current US guidelines for dairy milk consumption could be viewed with some caution. Why might there be an association? Fraser speculates that it could be from the sex hormone content of dairy milk, as breast cancer is hormone-responsive cancer. As well, some research has found that consuming dairy products is associated with higher blood levels of insulin-like growth factor-1 (IGF-1), a hormone believed to promote certain cancers.  
Limitations of the study include that it was observational, the participants were asked only one time at the beginning of the study what foods/beverages they consumed in the last 24 hours and how often they ate certain foods which could change over the course of almost 8 years, and data was “self-reported” which can be prone to error. Interestingly, while yogurt and cheese are dairy products they did not show an association with breast cancer risk.  

Until more research is done, Fraser advises people to substitute soy for cow’s milk because it is easy to do. “The recommendations I make are more along the lines of ‘caution.’ If you’re at high risk of breast cancer, maybe take this advice more seriously.”  He feels there is an “urgent need for future research.” The study authors acknowledge that dairy milk does have positive nutritional qualities.

Keep in mind, however, the comments by Registered Dietitians Sue Mah & Lucia Weiler, Co-Founders of n4nn, who state that “dietary guidelines are shaped by evidence-based studies, not just a single study.” Registered Dietitian and blogger Abbey Langer, in her review of the study, adds that a limitation of the study is that the women who were diagnosed with cancer had other risk factors beyond ‘milk’ such as being less active, having higher BMI and eating more processed meat. She is of the opinion that, given the limitations of the study, “If you drink milk, there is no compelling evidence – still – that it increases cancer risk.”

Elizabeth Holmes, manager of health policy at the Canadian Cancer Society, told Global News that the while the study adds to the overall body of evidence looking at dairy consumption and cancer risk, “More  research is needed to understand the link between dairy products and cancer risk before any conclusions can be made.” The American Cancer Society agrees, stating, “Some early studies raised concerns about whether drinking milk from cows treated with hormones can raise the risk of breast cancer or other types of cancer. But later studies failed to find a clear link. At this time, it is not clear that drinking milk produced with or without hormone treatment is of concern regarding cancer risk or other health effects.”

Dietitians of Canada have weighed in on the study. They point out that the study authors acknowledge that dairy milk has positive nutritional qualities and more research is needed to understand whether there is a true link between dairy intake, or other closely-related unidentified factors, and breast cancer risk. For reducing the risk of breast cancer, the Dietitians of Canada position is that “Until further research is available, dietitians can continue to review healthy lifestyle behaviours with clients including eating a balanced and varied diet that includes lots of vegetables, fruit, and whole-grain foods; engaging in regular physical activity; and avoiding smoking.”

Sources: Medical News Today website, Harvard Men's Health Watch website, Harvard TH Chan School of Public Health website, Harvard TH Chan School of Public Health website, Harvard TH Chan School of Public Health website, Abbey Langer Nutrition website, Dietitians of Canada PEN, The Global Resource for Nutrition Practice website, Global News website, Nutrition for Non-Nutritionists website, American Cancer Society website 
 

 
 
Water and Kidney Stones

Kidney stones develop when chemicals become concentrated enough in the urine so that crystals form that grow into stones. These stones can travel through the urinary tract, causing pain if they get stuck and the flow of urine is blocked. The most common stone is calcium oxalate stones (when calcium combines with oxalate in the urine). Inadequate calcium and fluid intake, as well as other conditions, may contribute to their formation. Both oxalate and calcium levels increase when the body doesn't have enough fluids and too much salt.

The number of cases of kidney stones is increasing and the chances of having a recurrence are high. According to the US National Kidney Foundation, it is estimated that one in ten people will have a kidney stone at some time in their lifetime. Harvard Men’s Health Watch reports that about half of the people who experience kidney stones can expect a recurrence within seven years without taking preventive measures.  

Based on this information, a Cochrane Review was done to look at the evidence comparing the effects of increased water intake for the prevention of kidney stones in people who have had kidney stones (secondary prevention) and who have not had kidney stones (primary prevention). Randomized controlled trials and quasi-randomized controlled trials were reviewed up to October 2019. Limited evidence was available e.g., only one randomized controlled trial looked at the effects of increasing water versus standard water intake for the prevention of kidney stones in people with a history of kidney stones. This study had 220 participants equally split between an intervention group who drank more water (i.e., at least 2 litres per day of water) compared to a control group who drank a “standard” amount of water. This study found that drinking more water may decrease the recurrence of kidney stones (149 fewer kidney recurrences per 1000 participants with 270 kidney stone recurrences per 1000 participants over five years in the control group who drank a standard amount of water). No randomized controlled trials have looked at the role of increasing water intake for the primary prevention of kidney stones.

The study's conclusion was that drinking more water may reduce the risk of recurring kidney stones (kidney stones coming back). It may also extend the time it takes for the stones to come back. No evidence was found of unwanted effects. The investigators note that the certainty of the evidence for both key results was low, which they explain means that the “true results may be quite different.” In other words, confidence in these findings is limited.

Bottom line: Increasing water intake to achieve a urine volume of at least 2 litres per day may reduce kidney stones from coming back and prolonging the time to recurrence for people with a history of kidney stones.

Why might water help with the prevention of kidney stones?
Water dilutes the substances that form kidney stones. You can add citrus beverages like lemonade and orange juice (small amounts due to sugar content) because the citrate will help block stone formation. The Kidney Foundation explains that most of the fluid you drink should be water as it is better than soda, sports drinks, or coffee/tea. 

Other ways to prevent kidney stones
In addition to drinking water, other ways to prevent kidney stones include:
  • Maintain a healthy weight.  
  • Reduce your sodium intake because high sodium can increase the amount of calcium in the urine (if you are prone to kidney stones, the recommendation is to follow a low-sodium diet, which is also beneficial for preventing high blood pressure).
  • Watch your animal product intake e.g., red meat, poultry, eggs, and seafood. These increase uric acid levels and reduces citrate, a chemical in urine that helps prevent the formation of kidney stones. Look at eating a daily portion of meat that is the size of a deck of cards. Focus on more fruits and vegetables as these make the urine less acid and stones are less able to form.
  • Be aware of stone-forming foods e.g., foods high in oxalates such as beets, chocolate, spinach, rhubarb, tea, most nuts, and phosphorous colas.
  • Limit your intake of sugar-sweetened beverages.
To prevent a recurrence, it’s important to know which type of kidney stone you had. For the most common stone, calcium stones, the Unlockfood website suggests:  
  • Ensure your caffeine intake is less than 400 mg a day (no more than 2 to 3 cups of brewed coffee a day).
  • Drink alcohol at levels less than indicated in Canada's low-risk drinking guidelines.
  • Do not exceed more than 1000 mg of vitamin C supplements daily. 
Note that when it comes to diet and kidney stones, the American Urological Association reports that there is no “one-size-fits-all” diet for preventing recurring kidney stones. Everyone is different.

Resources Sources: McMaster Optimal Aging Portal website, National Kidney Foundation website, Harvard Health Blog website, Harvard Men's Health Watch website, Unlockfood website
 

 



Osteoarthritis Online Resources
  • Do you or someone you care for have osteoarthritis of the hip or knee? McMaster University's Optimal Aging Portal has a free online interactive lesson to learn how to manage osteoarthritis through exercise and weight management. This information will help you to reduce your symptoms and improve your mobility. 
  • The Arthritis Society website provides online education on its website, including a module on pain management.
  • HealthLink BC has information on osteoarthritis including a health tools section
  • The Osteoarthritis Action Alliance (US)  is supported, in part, by the US Centers for Disease Control and Prevention. The Thurston Arthritis Research Center (TARC) at the University of North Carolina at Chapel Hill is the lead agency. The website provides information on living with osteoarthritis. 
  • Physical Activity Services at HealthLink BC provides physical activity information and advice from a qualified exercise professional (Monday to Friday, 9 am to 5 pm Pacific Time). This service was previously offered by the Physical Activity Line (PAL). You can call them by dialing 8-1-1 or email them. Visit the website for more information. 
  • Knees and Hips online course from Harvard Medical School Harvard Health Publishing - there is a fee that allows unlimited lifetime access to this interactive online course. It shares the most effective strategies to treat 23 common hip and knee problems, plus what you should know about today’s advances in hip and knee replacement.
  • For pain management information, Pain BC has a Toolbox available on its website. During the COVID-19 pandemic, Pain BC is offering free Gentle Movement @ Home live-streaming sessions that provide guided movement and relaxation for people living with pain from the comfort of their homes. Sessions are led by a physiotherapist or occupational therapist. For more information and to register, please visit the website
 



Canadian Pain Task Force Online Consultation

In the spring of 2019, Health Canada established the Canadian Pain Task Force (CPTF) to recommend an improved approach to pain care, education, research, and data monitoring in Canada.

As part of its mandate, the Canadian Pain Task Force has launched a public consultation to learn more about the issues, needs, and priorities that matter most to Canadians in order to improve how pain is understood and managed in our country. The consultation is open to anyone with an interest in pain, including people living with pain, caregivers, health care providers, researchers, policymakers, and the general public. The input received from this public consultation will help inform the Task Force’s second report to Health Canada in June 2020, which will outline elements of an improved approach to pain in Canada. Please share your ideas, knowledge, and experience to let them know what is working, what is not working, and what can be done to improve the lives of people impacted by pain. Visit the Government of Canada website link for more information.
 

 
Please send your ideas and suggestions to theloop@uvic.ca.
 


Self-Management BC is supported and funded through a partnership with the Patients as Partners Initiative within the BC Ministry of Health.
 
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This information and research are intended to be reliable, but its accuracy cannot be guaranteed. All material in this e-newsletter is provided for information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this e-newsletter. Readers should consult their doctor or another qualified health professional on any matter relating to their health and well-being. The information and opinions provided in this e-newsletter are believed to be accurate and sound, based on the best judgment available to the authors. Readers who fail to consult with appropriate health authorities assume the risk of any injuries. The publisher, Self-Management BC, is not responsible for any errors or omissions. Self-Management BC is not responsible for the information in these articles or for any content included in this article which is intended as a guide only and should not be used as a substitute to seeking professional advice from either your doctor or a registered specialist for yourself or anyone else. 
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