GreenField Health’s Health Matters: May 2006
Energy Drinks
Attention Deficit Hyperactivity Disorder
A Warning on Stimulants Used to Treat ADD
Announcements
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Energy Drinks
The number of “energy drinks” available on the market has grown dramatically over the past few years. Grocery store shelves are stocked with a wide variety, and they aren’t inexpensive. Are these drinks worth your money and attention? Do they actually give you energy?
The reality is that they have little real value either nutritionally or from an energy-boosting perspective. When you check out the ingredients, you might find a list of vitamins or other nutrients put there to make the product look impressive, but those ingredients are for marketing purposes and provide very little actual value to your body. The energy boost in these drinks tends to come in two forms – caffeine and sugar. The sugar is in the form of high fructose corn syrup or the like.
From a health and energy perspective, these “energy drinks” are no different than the average cola or soda containing caffeine and sugar. They provide empty, non-nutritious and fattening calories. Calling them “energy drinks” is nothing more than a marketing ploy.
What about athletes? Some might argue that energy drinks are really targeted toward athletes, but that isn’t true either. For the average athlete that jogs now and again, no special nutritional supplement, replenishing solution, or re-hydrating beverage is necessary. Tap water will do just fine.
True endurance athletes who exercise regularly and vigorously for long periods of time do need to consume electrolyte solutions that are designed to replace bodily salts while providing calories at the time of high energy output, mainly during endurance events. Such drinks are helpful because they are used during heavy exertion when the athlete is consuming large amounts of energy and losing electrolytes in sweat. Such drinks are not intended to be used during casual exercise or as a “pick-me-up” during the day, and they are very different than the widely available “energy drinks”.
Least you think that we’re out of touch, we do understand that a pick-me-up can be desirable at times and is often sought in the form of a double espresso, large latte, or something of that nature. However, we don’t want you to be fooled into believing that the so-called energy drinks provide any significant benefit. The same goes for energy bars that are also widely available. They provide little real value although some of them are more favorably formulated such as Odwalla Bars and the Paley’s Bar.
We recommend that you save your money and avoid energy drinks as well as sodas, pops, soft drinks, and most energy bars. If you need an energy boost, try a piece of fruit, some nuts, or an inexpensive and nutritionally balanced snack. While we certainly understand the occasional stop at the coffee shop to increase your energy, you might want to try a brisk walk or quick hike up a few flights of stairs to get your blood pumping – exercise is in fact the best way to energize your body.
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder (ADHD or ADD) was originally believed to be primarily a childhood condition. However, data suggest that between 30 – 70% of children with ADD continue to manifest symptoms in adulthood. This leads to an estimate that between 1 – 7% of adults experience ADD. In fact, the diagnosis of ADD in adults and the use of medications to treat it grew by 90% between 2002 and 2005. Having read about these conditions in the press, some patients have begun requesting treatment.
The challenges with diagnosis of ADD include the common occurrence of ADD-like symptoms in the general population and criteria that are not objectively verifiable but rather rely on an individual’s subjective reports of symptoms. For example, because of reports in the popular press, a high number of adults are self-diagnosing ADD, but studies suggest that only one-third of adults who believe they have ADD actually meet formal criteria.
The diagnostic criteria for ADD emphasize both inattention and hyperactivity-impulsivity. These symptoms best describe ADD in children with the condition being more subtle in adults. Poor concentration, distractibility, elevated physical activity, and impulsivity should be pervasive features disrupting at least two of three domains of daily life: school or work, family, and relationships. Symptoms should be persistent and present since age seven.
There is a growing consensus that the central feature of ADD in adults is disinhibition. This typically manifests as poor self-regulation and difficulty with both focused attention and goal-directed thought and action. Adults with ADD are unable to prevent immediate responses during inappropriate situations and have deficits in their ability to monitor their own behavior.
Hyperactivity, while a common feature among children, is less overt in adults. The "on the go" and driven behavior seen in many ADD children is replaced with restlessness, difficulty relaxing, and feeling chronically "on edge." Problems with attention and concentration may become more apparent in late adolescence and early adulthood as responsibilities increase. Affected individuals may frequently miss appointments, social commitments, and school and work deadlines. Completed work is frequently misplaced amid clutter. Adults with ADD are often disorganized because they have problems prioritizing tasks and breaking tasks down into subparts.
Impulsivity and emotional instability can take the form of socially inappropriate behavior such as blurting out inappropriate thoughts that are rude or insulting and emotional symptoms such as sudden angry outbursts that they may describe as personally uncontrollable.
Just because you have some of the symptoms of ADD does not mean that you have ADD. A large percentage of “Type-A” personalities have similar symptoms. Individual symptoms are very common. To make the diagnosis of ADD, multiple symptoms have to have been present over time, and the symptoms have to have had adverse social consequences. The diagnosis is based on an interview with the patient and the solicitation of current and past history demonstrating a persistent history of inattention and hyperactivity dating to at least age seven. We will not list formal diagnostic criteria here, but they are publicly available at http://www.aafp.org/afp/20001101/2077.html.
What causes ADD? ADD appears to be caused by an imbalance of adrenalin (epinephrine) metabolism in the brain much like depression appears to be associated with abnormal serotonin metabolism. And while there is a lot of work being done in this area, a great deal remains unknown because it is challenging to precisely understand what is happening at the level of the individual cells and at the level of the synapse in the human brain. The synapse is the very tiny area between two nerves through which the nerves communicate using “neurotransmitter” chemicals such as epinephrine and serotonin.
How is ADD treated? Medications are the mainstay of ADD treatment. The traditional medications used are stimulants including the methylphenidates Ritalin, Concerta, Methylin and Metadate and the amphetamine Adderall. The extra stimulation appears to actually assist the brain with focusing and attention.
In fact, while it is not discussed much in the medical literature, it is apparent that many people who might be categorized as having ADD or borderline ADD but who have never been formally diagnosed have treated themselves very successfully over the years with daily exercise. These individuals learned early in life that their attention, concentration, and organization were much better when they exercised regularly, so that their exercise provides the stimulant that the brain desires.
In our culture, which tends to be more focused on medications than good lifestyle changes, it would actually be quite interesting to see a head-to-head trial of stimulant medication versus daily exercise in treating ADD. It is possible that the rise in the diagnosis of both childhood and adult ADD is related to the general reduction in physical activity seen in the US.
Nonetheless, stimulants are currently the most commonly used medications. However, as is discussed below, there is an increasing concern about possible side effects of stimulants. In addition to stimulants, data is accumulating on some nonstimulant medications such as atomoxetine (Strattera), the tricyclic antidepressants such as amitriptyline (Elavil), desipramine (Norpramin) or nortriptyline (Pamelor or Aventyl), and the antidepressant buproprion (Wellbutrin). While these medications may be classified as “antidepressants,” they are actually used for a wide variety of conditions and they work through an alteration in epinephrine metabolism. There are limited data comparing the stimulants to antidepressants, but the available research suggests that they are similarly effective.
Adult ADD is a chronic, life-long condition continuing from early childhood. Thus, continued pharmacotherapy throughout adulthood is usually indicated. Little is known about the long term effects of stimulant medication but concerns are growing as discussed below. It is also not known if long term stimulant therapy is associated with a greater incidence of adult substance abuse. It is possible that daily vigorous exercise may be equally as effective as medications in treating ADD, just as it compares very favorably to medications in treating depression.
A Warning on Stimulants Used to Treat ADD
In February 2006, an advisory panel to the US Food and Drug Administration (FDA) recommended the strongest possible label warning for Ritalin and other stimulants used to treat attention-deficit hyperactivity disorder (ADHD or ADD - attention deficit disorder) due to the potential cardiovascular risks such as heart attacks and strokes when these medications are used.
The medications used to treat ADD, and those of concern, include all stimulants commonly used to treat ADD including the methylphenidates Ritalin, Concerta, Methylin and Metadate and the amphetamine Adderall.
Concern about these medications came after reports of the deaths of 25 people, 19 of them children, and 54 cases of serious cardiovascular problems such as heart attacks and strokes in adults and children using these medications between 1999 and 2003. An earlier FDA review found less than one death or serious injury per 1 million ADD drug prescriptions filled and 1.79 cases of nonfatal cardiovascular or cerebrovascular problems per 1 million in adults treated with amphetamines.
The spiraling growth in use of these medications has spurred greater scrutiny. The drug Strattera now carries a warning that it may prompt suicidal thoughts in children. Last year, Adderall was briefly pulled from the market in Canada due to safety concerns. And, in July 2005, an FDA advisory committee considered but rejected labeling changes for Ritalin, Metadate and other methylphenidates. The panel also suggested that changes to Adderall and Strattera be delayed until more safety data was collected.
What do we recommend? For any medication, one must weigh the benefit of use against the risk. For these medications, there is a low risk associated with their use as described above, and we believe that they should be used with caution. Those patients with heart conditions or cerebrovascular problems should be particularly cautious with these medications.
Announcements
Welcome back Dr. Elizabeth Hays
Dr. Hays has returned from her maternity leave. She has resumed her schedule of working three days per week – Monday, Wednesday, and Thursday. While she is not in the office on Tuesdays and Fridays, other team members are always present to assist her patients and we communicate with her regularly regarding active patient issues. Please join us in a warm welcome back for Elizabeth.
First Tuesdays
Thanks for sending your friends and family members who are interested in becoming patients at GreenField Health to our First Tuesday open house. Upcoming First Tuesdays are June 6, August 1, and September 5. We’re skipping July 4 due to the holiday. They start promptly at 5:30 PM at GreenField.
Women & Heart Disease - Did you know that 1 out of 3 women will die from heart disease this year? Heart disease is the #1 killer of women.
Come and learn how a woman’s symptoms of a heart attack can differ from a man’s. We’ll also discuss risk factors, non-invasive tests, numbers you should know, and a heart healthy diet.
This free session is presented by Janice Isenberg, LCSW, who was selected to participate in the Mayo Clinic Science & Leadership Symposium for women with heart disease. Janice is living with heart disease herself.
Please join us on Tuesday, May 23 at 6:00PM at our offices at GreenField. Please RSVP to our main number (503-292-9560) as space is limited.
Welcoming Joanne Houck
Please join us in welcoming Joanne – she is working with us as an on-call Health Coordinator, and you may reach her when you call our office. Joanne has many years of experience in healthcare, and also with our electronic medical records software, making her a welcome addition to the team.
Office Notes
Please note that the office will be closed on Monday, May 29th in observation of the Memorial Day holiday. As always, one of our physicians will be available to you for urgent and emergent needs.
Thanks as always for the trust you place in us to assist with your healthcare. Please call or email us if there is anything we can do for you.
Thanks to our corporate partners
Kryptiq Corporation
Baker-Ellis Asset Management, LLC
Stahancyk, Gearing, Rackner, & Kent Law Firm
Go to our website to learn more about these corporate sponsors https://securemail.greenfieldhealth.com/Portal/General+Info/Corporate+Partners/Default.aspx
First Tuesday Reminder
The schedule for our
upcoming GreenField Health First Tuesday Open House is June 6th, August
1st, and September 5th. This is a good introduction to our practice for
relatives, friends or coworkers who might be interested in becoming a
GreenField patient. The sessions begin promptly at 5:30 PM on the first
Tuesday of each month. Learn more about our First Tuesday Open House
Online at: https://securemail.greenfieldhealth.com/Portal/General+Info/First+Tuesdays/default.aspx
Sincerely,
Your GreenField Health Team:
Beth Davis, your Benefits Coordinator and Biller- beth.davis@greenfieldhealth.com
Chuck Kilo, MD - chuck.kilo@greenfieldhealth.com
Cynthia Ferrier, MD - cynthia.ferrier@greenfieldhealth.com
Dia Gaede, CMA, your Health Coordinator - dia.gaede@greenfieldhealth.com
Elizabeth Hays, MD - elizabeth.hays@greenfieldhealth.com
Eric Murray, MD - eric.murray@greenfieldhealth.com
Heidi Downey, your Consultant - heidi.downey@greenfieldhealth.com
Jill Arena, your Clinic Administrator - jill.arena@greenfieldhealth.com
Joel Swartzmiller, IT Manager - joel.swartzmiller@greenfieldhealth.com
Lindy Thornbloom, your Health Coordinator - lindy.thornbloom@greenfieldhealth.com
Pam Mockenhaupt, CMA, your Health Coordinator - pam.mockenhaupt@greenfieldhealth.com
Paula Koeller, MD - paula.koeller@greenfieldhealth.com
Shelly Banta, your Clinic Manager - shelly.banta@greenfieldhealth.com
Tiana Schmitt, CMA, your Health Coordinator - tiana.schmitt@greenfieldhealth.com
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GreenField Health System
9427 SW Barnes Road, Suite 590
Portland, OR 97225
Phone: 503-292-9560
Fax: 503-292-9510
Web: http://www.greenfieldhealth.com
Questions, concerns, comments appreciated:
questions@greenfieldhealth.com
copyright 2003-2006 GreenField Health
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