Important Things to Remember About Recreational and Medical Use of Marijuana

A bird in Maui. (Dr. Noorali Bharwani)

Dr. Sanjay Gupta, Neurosurgeon and Chief Medical Correspondent for CNN is reported to have said, “Every 19 minutes somebody dies of a prescription drug overdose. It doesn’t happen with marijuana.” In the past Gupta was against legalising medical marijuana in the U.S. but now he is in favour of it. He sees some benefit for certain types of illnesses.

The use of medical marijuana (medical cannabis) as a medicine has not been rigorously tested due to several restrictions. But there is some evidence to suggest cannabis can reduce nausea and vomiting during chemotherapy, improve appetite in people with HIV/AIDS, and reduce chronic pain and muscle spasm.

Medical marijuana can improve sleep, and improve tics in Tourette syndrome. When usual treatments are ineffective, cannabinoids have also been recommended for anorexia, arthritis, migraine, and glaucoma. It should not be used in pregnancy.

Use of marijuana is not without side effects such as: dizziness, feeling tired, vomiting, and hallucinations. There is some concern about the long-term use of marijuana. It may cause memory loss, addiction, and schizophrenia.

Recreational use of cannabis is illegal in most parts of the world, but the medical use of cannabis is legal in certain countries, including Canada and 29 states in the U.S.

A cannabis plant includes more than 400 different chemicals, of which about 70 are cannabinoids. In comparison, typical government-approved medications contain only one or two chemicals. The number of active chemicals in cannabis is one reason why treatment with cannabis is difficult to classify and study.

Articles in the Canadian Medical Association Journal (CMAJ September, 2017) make few important points on the use of medical marijuana:

  1. Despite widespread availability, medical marijuana is still experimental.
  2. Use of medical marijuana can increase the risk of motor vehicle collision.
  3. The drug should be titrated slowly with low initial dosing.
  4. Users of medical marijuana may be vulnerable to psychosis.
  5. Recreational and medical marijuana are not equivalent and therefore, should have different frameworks for access.
  6. User should remember there are substantial gaps in our knowledge on the use of medical marijuana.
  7. More vigorous research is required to make better use of this drug.

“I do want to mention a concern that I think about as a father. Young, developing brains are likely more susceptible to harm from marijuana than adult brains. Some recent studies suggest that regular use in teenage years leads to a permanent decrease in IQ. Other research hints at a possible heightened risk of developing psychosis,” says Gupta in one of his articles.

On August 11, 2016, Health Canada announced the new Access to Cannabis for Medical Purposes Regulations (ACMPR). The ACMPR allow for reasonable access to cannabis for medical purposes for Canadians who have been authorized to use cannabis for medical purposes by their health care practitioner.

These individuals will continue to have the option of purchasing safe, quality-controlled cannabis from one of the producers licensed by Health Canada. Canadians will also be able to produce a limited amount of cannabis for their own medical purposes, or designate someone to produce it for them.

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Statistics Show Majority of Canadians Overweight and Overfat

Photograph by Dr. Noorali Bharwani.

According to Statistics Canada, 61.3 per cent of adult Canadians were overweight or obese in 2015, says an article in the Canadian Medical Association Journal (CMAJ August 31, 2017). That means three in five Canadians are overweight or obese.

In 2015, the percentage of those who were obese rose to 26.7 per cent, up from 23.1 per cent in 2004. Obesity has continued to increase in adult men and women who are age 60 years and older.

Researchers warn us focusing on body mass index (BMI) misses the risks of high body fat in people of normal weight.

BMI is a person’s weight in kilograms divided by the square of height in meters. BMI does not measure body fat directly. But BMI is an inexpensive and easy-to-perform method of screening for weight category.

Your BMI may be normal for your height and weight but you may still have more fat than is good for you. It may misclassify someone who is short and muscular.
On the other hand a high BMI can be an indicator of high body fatness.

BMI can be used for population assessment of overweight and obesity. Because calculation requires only height and weight, it is inexpensive and easy to use for clinicians and for the general public. BMI can be used as a screening tool for body fatness but is not diagnostic.

How is BMI interpreted for adults (over age 20)?

  1. BMI below 18.5 – underweight
  2. BMI 18.5 to 24.9 – normal or healthy weight
  3. BMI 25.0 to 29.9 – overweight
  4. BMI 30.0 and above – obese

The question is – Is BMI the best way to measure obesity?

The CMAJ article says, “A provincial spokesperson for Manitoba (where child obesity is climbing) questioned the value of the measurement because BMI does not consider lifestyle behaviours like dietary quality, physical activity, which are, in fact, stronger determinants of death and disease.”

The CMAJ article goes on to give many examples where BMI may not accurately reflect a person’s risk of serious obesity related illnesses. Incidence of coronary heart disease, stroke, cancer and type 2 diabetes is higher in overweight and obese person.

A recent study in Frontiers in Public Health (July 24, 2017) by Philip B. Maffetone and colleagues say using BMI to measure obesity likely underestimates the problem. They propose measuring a person’s waist instead of their weight to assess health risks. Abdominal fat or obesity has more severe health effects than fat in other parts of the body.

A person has to reduce abdominal girth to reduce adverse health risks. A person’s waist should be less than half their height. This waist-to-height ratio may be the single best clinical indicator of health risk as it can be used throughout childhood, into adult life, as well as throughout the world.

Most clinicians usually know if the patient in front of them has too much body fat. They should not have to wait for the latest consensus to encourage lifestyle changes: lose weight, make dietary quality changes and increase physical activity. Simply put… eat less and exercise more.

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Hereditary Cancer and the Importance of BRCA Gene Testing

Antigua (Dr. Noorali Bharwani)

Longtime Newfoundland and Labrador politician, Judy Foote, has resigned as federal cabinet minister.

Foote made the move to spend more time with her family after learning she has the BRCA gene, which is hereditary and can impact her children. BRCA stands for breast cancer.

Foote said she has had two bouts with cancer, but as far as she knows, she is now cancer-free. That is good news.

BRCA testing uses DNA analysis to identify harmful changes that signal a higher risk for breast and ovarian cancer.

If a positive DNA mutation (changes in the structure of a gene) is discovered in one person, other family members can be tested to determine if they also carry a BRCA mutation. A genetic counsellor can make you understand your personal risks and prevention strategy.

About one in 200 women in North America carry a BRCA1 or BRCA2 mutation. But among certain ethnic groups the prevalence is considerably higher. The frequency in those of Ashkenazi (Eastern European) Jewish ancestry is one in 50. Other groups with high frequencies of mutations include women from Iceland and Poland.

Actor Angelina Jolie had a double mastectomy due to the presence of BRCA gene. Actor Pierce Brosnan’s daughter Charlotte Emily died of ovarian cancer at age 42. Brosnan is a former James Bond star whose first wife, Cassandra (Charlotte’s mother), also passed away due to the same disease in 1991 when she was 43.

We know if you have a family history of ovarian cancer then the risk of ovarian cancer increases amongst women in that family.

What is the difference between BRCA1 and BRCA2 genes?

The types of cancers associated with the two genes are different. Carriers of BRCA1 gene mutation have a slightly increased risk of ovarian cancer compared to those with BRCA2.

It is also known that carriers of BRCA2 genes have risks of different types of cancers, including pancreatic cancer and melanoma. For men with the BRCA2 mutation, there is an increased risk of both prostate and breast cancers.

Who is eligible for BRCA genetic testing?

A person who has:

  • A strong family history of cancer
  • The cancer must have occurred in young ages within the family
  • If you are a member of ethnic groups known to be affected
  • Based on your personal and family history a genetic counsellor can recommend BRCA genetic testing

Early detection of breast cancer has dramatically changed the prognosis of the disease. We cannot say the same thing about ovarian cancer because we do not have any tests for early detection.

More than 60 per cent of the women with ovarian cancer are in advanced stage when first diagnosed. Their five-year survival rate is less than 30 per cent. Their prognosis is poor and they have very few treatment options.

To summarise, having a BRCA gene mutation is uncommon. Inherited BRCA gene mutations are responsible for about 5 to 10 percent of breast cancers and about 15 percent of ovarian cancers. If you have a personal or family history of breast or ovarian cancer then discuss your options with your doctor. Also understand the ethical, legal, and psychosocial implications of what you find. Check if the findings will affect your insurance policy.

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Death of Comedian Robin Williams and the Tragic Effect of Dementia

Maui, Hawaii (Dr. Noorali Bharwani)

Dementia is a general term for loss of memory and other mental abilities severe enough to interfere with daily life. It is caused by physical changes in the brain. There are at least 10 different types of dementia.

Alzheimer’s disease is the most common type of dementia and accounts for an estimated 60 to 80 percent of cases.

Lewy body dementia is a progressive disease and is the second most common type of progressive dementia. It affects 1.4 million Americans.

Actor comedian Robin Williams, a man who entertained and made millions of people laugh, committed suicide on August 11, 2014. Questions were raised on the state of his mind and health at the time of his tragic death. At autopsy, the brain of Williams showed signs of diffuse Lewy body disease.

The Lewy Body Dementia Association website has a clarifying statement on the autopsy report on Williams. It goes on to explain the effect of Lewy body dementia.

Before his death, Williams had a clinical diagnosis of Parkinson’s disease and received treatment for his symptoms. He also suffered from depression, anxiety and paranoia, which may occur in either Parkinson’s disease or dementia with Lewy bodies.

In the early 1900s, while researching Parkinson’s disease, the German-born American neurologist, Friederich H. Lewy, discovered abnormal protein deposits that disrupt the brain’s normal functions. Lewy body dementia exists either in pure form, or in conjunction with other brain changes, including those typically seen in Alzheimer’s disease and Parkinson’s disease.

Lewy body dementia is a progressive disease. It causes a decline in mental functions. There may be visual hallucinations, and changes in alertness and attention. They may have Parkinson’s disease-like symptoms such as rigid muscles, slow movement and tremors.

In early Parkinson’s disease, Lewy bodies are generally limited in distribution, but in dementia with Lewy bodies, the Lewy bodies are spread widely throughout the brain, as was the case with Williams.

To make a clinical diagnosis of dementia with Lewy bodies, a person must have significant problems with thinking and memory that interfere with everyday life. There was no mention in the media or in the autopsy report that Williams exhibited these symptoms. But it is not uncommon for early signs of dementia to go unnoticed.

Making diagnoses of Lewy body dementia is not easy because it is a complex disease that can present with a range of physical, cognitive, and behavioural symptoms. Symptoms that can closely resemble other more commonly known diseases like Alzheimer’s and Parkinson’s. That is why it is widely undiagnosed. It can dramatically affect not only the person diagnosed but also the primary caregiver – usually the family.

Early and accurate diagnosis of Lewy body dementia, while not always easy, is of critical importance for better management. If they are misdiagnosed to have Alzheimer’s disease or Parkinson’s disease then they may react to medications differently. They need multidisciplinary treatment from different specialists.

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Genetic Testing and the Burden of Knowing Your DNA

To jump or not to jump. (Dr. Noorali Bharwani)

You have seen the commercials about genetic testing. I am sure you have been tempted to get the test done for yourself. Then you ask, “How much do I want to know about the unknown?” Well, read-on and find out.

Genetic testing involves examining your DNA. DNA is the chemical database that carries instructions for your body’s functions. Genetic testing can reveal changes in your genes that may cause disease. Remember, genetic testing is not perfect.

Different types of genetic testing are done for different reasons. There are at least seven different reasons why DNA test would be indicated. These are: diagnostic testing, presymptomatic and predictive testing, carrier testing, pharmacogenetics, prenatal testing, newborn screening, and preimplantation testing.

A positive test does not always mean you will develop a disease. A negative result does not guarantee you won’t have a certain disorder. If you plan to take the test then you should know what you plan to do with the results.

What are the advantages of genetic testing?

  1. Genetic testing plays a vital role in determining the risk of developing certain diseases as well as screening and sometimes medical treatment.
  2. With a positive result, in some cases, you can make lifestyle changes that may reduce your risk of developing a disease, even if you have a gene that makes you more susceptible to a disorder.
  3. Positive results may help you make choices related to treatment, family planning, careers and insurance coverage.
  4. You may choose to participate in research or registries related to your genetic disorder or condition.

What are the disadvantages of genetic testing?

  1. Genetic testing can have emotional, social and financial risks.
  2. It may affect rest of your family. Discuss with them before you go for the test. Find out how your family might respond to your test results and how it may affect them.
  3. Find out if it is going to affect your work.
  4. What about your life insurance policy – how would that be affected?
  5. A negative result does not mean you don’t have the disorder.
  6. Sometimes it can be difficult to distinguish between a disease-causing gene and a harmless gene variation.

It will be wise to get genetic counseling before and after you get the test. This may be in the form of your doctor, medical geneticist or genetic counselor. This will help you understand what the results mean for you and your family.

To summarize, genetic testing has potential benefits whether the results are positive or negative. Your test results can provide a sense of relief from uncertainty and help you make informed decisions about managing your health.

A positive result can encourage you to take preventive measures. Some test results can help people make decisions about having children. Screening in newborns can identify genetic disorders early in life so treatment can be started as early as possible.

Your family physician will always provide you care that is within the limits of his/her knowledge. Your physician will ask for a consult with a specialist in genetics if appropriate. Your physician will respect your right to make autonomous decisions in looking after your health.

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A Dangerous Trio – Snoring, Sleep Apnoea and High Blood Pressure

Keep smiling, it makes people wonder what you are upto! (Dr. Noorali Bharwani)

Reports indicate nearly eight in 10 married couples say their partner has a sleep problem, like snoring, insomnia, or incessant tossing and turning. Sleep difficulties force their partners into separate sleeping quarters. More than 20 per cent say they are too sleepy for sex.

You can blame this on too much work, stress, caffeine, nicotine, alcohol, 24-hour cable TV, the Internet and email.

Lack of sleep has consequences like increased blood pressure that raises the risk of heart attacks and stroke. Diabetes and obesity have also been linked with chronic sleep loss. People who do not get enough sleep are more than twice as likely to die of heart disease.

To stay awake people tend to eat more and that means they put on weight. They smoke more and drink too much coffee and alcohol. That means they are prone to motor vehicle collisions. They hurt themselves and hurt others.

For optimal health it is important for adults to consistently sleep around seven hours each night. When we sleep, the body rests and restores its energy levels. A good night’s sleep will help us cope with stress, solve problems and help us recover from illness.

If you have sleep problem then seek help. There are many ways to help diagnose and treat sleep disorders including snoring. Your family doctor can refer you to a sleep clinic.

We know heart disease is the leading cause of death in advanced industrialized countries, and stroke is also a leading cause of death and disability.

American Heart Association wants you to know that the evidence is very strong for the relationship between sleep apnoea and hypertension and cardiovascular disease generally. If you are a snorer and have sleep apnoea then get proper treatment.

In a sleep study, doctors count pauses in breathing to determine whether the patient has mild sleep apnoea, characterized by five to 15 episodes per hour; moderate sleep apnoea, defined by 15 to 30 per hour; or severe sleep apnoea, meaning more than 30 each hour.

A sleep clinic can get you started with investigations and treatment known as continuous positive airway pressure (CPAP). The CPAP device involves wearing a mask while sleeping. It keeps the breathing passages open and oxygen flowing. It can yield fast results. Blood pressure comes down quickly. This improves your prognosis.

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Proper Use of Sunscreen Important to Prevent Skin Cancer

"Trust me, I'm a doctor!" (Dr. Noorali Bharwani)

Skin cancer is the most common cancer in North America. The benefits of sunscreen outweigh the inconvenience of using it.

First step in the prevention against skin cancer is to avoid sun exposure between 10 a.m. and 2 p.m. whatever the season. These are prime hours for exposure to skin-damaging ultraviolet (UV) radiation from the sun, even on overcast days.

Second step is to wear protective clothing. This includes pants, shirts with long sleeves, sunglasses and a wide-brimmed hat.

Third step is to use sunscreen. Apply sunscreen generously and reapply regularly, says a dermatologist at Mayo Clinic.

There are two types of UV light that can harm your skin – UVA and UVB. A broad-spectrum sunscreen protects you from both.

UVA rays can prematurely age your skin, causing wrinkles. UVB rays can burn your skin. Too much exposure to UVA or UVB rays can cause skin cancer. The best sunscreen offers protection from all UV light.

SPF stands for sun protection factor, a measure of how well sunscreen protects against UVB rays. UVA protection isn’t rated. Manufacturers calculate SPF based on how long it takes to sunburn skin that’s been treated with the sunscreen as compared to skin with no sunscreen.

When applied correctly, a sunscreen with an SPF of 30 will provide slightly more protection from UVB rays than does a sunscreen with an SPF of 15. But the SPF 30 product isn’t twice as protective as the SPF 15 product. Sunscreens with SPFs greater than 50 provide only a small increase in UV protection.

Often sunscreen is not applied thoroughly or thickly enough, and it can be washed off during swimming or sweating. As a result, even the best sunscreen might be less effective than the SPF number suggests.

Rather than looking at a sunscreen’s SPF, choose a broad-spectrum sunscreen. A water-resistant sunscreen means the SPF is maintained for up to 40 minutes while swimming or sweating. Very water resistant means the SPF is maintained for 80 minutes.

Is one sunscreen better than others?

Experts at Consumer Report (May 2017) tested 62 lotions, sprays, sticks, and lip balms. Out of these, 23 tested at less than half their labeled SPF number. That doesn’t mean the products aren’t protective, but you may not be getting the degree of protection you think you are.

To compare the full list of sunscreens you will have to go to the Consumer Report. Here are the top five brands mentioned in the Report:

  1. Equate Sport Lotion SPF 50 (Walmart)
  2. Pure Sun Defense Lotion SPF 50
  3. Equate Ultra Protection Lotion SPF 50 (Walmart)
  4. Trader Joes Spray SPF 50+
  5. Equate Sport Continuous Spray SPF 30 (Walmart)

If you cannot find one of the above sunscreens, then choose a chemical sunscreen with an SPF of 40 or higher that will give you a better chance of getting at least SPF 30.

How to use the sunscreen?

  1. Shake it well.
  2. Apply 15 to 30 minutes before going out.
  3. Use at least a teaspoon on each body part.
  4. Reapply every two hours.
  5. Use spray sunscreens carefully so you don’t inhale it, they can also be flammable. Avoid using sprays on children.

Be safe and enjoy the summer.

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