Monthly Archives: December 2018

Most Pharmacies have a patient (or more) that is a centenarian.  Living to the age of 100 is quite an achievement, considering these patients grew up and lived the prime of their lives in an era that had a healthcare model quite different from today.  Knowledge of how diet, exercise, nutrition and medicine interplay to result in a long life wasn’t as advanced as it is today.  Some may say the diet 100 years ago was superior to today’s diet.  They probably wouldn’t be wrong.  Sanitation, pasteurization, and crop control were at a different stage at this point in time than they are today.

I had the pleasure of sitting down with Margaret MacPhee, 103 years old from Baddeck, Nova Scotia recently to ask her what her life experiences that may have helped get her to this age.  In an interview that was hopefully not patronizing, she opened up about her life from childhood to today.

Margaret was born at home during the wintertime of 1915 and grew up in a house in Upper Baddeck (Big Baddeck) the fourth oldest child in a family of 11.  She wonders how she managed to be living at all growing up back then let alone survive to be 103.  Her house had no electricity or phone and was heated from one central stove.  Her father was a farmer and her mother “had lots to do with all the children”.  This was not uncommon for the families that grew up in the area as every family seemed to be large.  She went to school in Upper Baddeck for 11 years then went out working from home to home in the area doing housework.  She was married to Charles D MacPhee in 1946 until he passed away in 1992.  They had one daughter (Catherine), a large difference from her family size growing up.

Margaret didn’t smoke or drink alcohol during her life.  She didn’t recall taking any type of vitamin or herb growing up.  As a child she doesn’t directly recall most of the healthcare or medicine of the time.  She recalls early in her life coming home from Sydney and then coming down with Scarlet Fever.  She doesn’t remember what Dr MacMillan gave her at that point but she survived this.  She clearly tells about being quarantined alone in her room where her mother soaked a blanket and hung it in the doorway of the room to keep the germs from spreading to the rest of the house.  Given the lack of modern day entertainment sources for children back then, it must have been a lonely time for Margaret during the long hours of the days and nights while she recovered.  No one else came down with the disease in the house.  She also had measles and as well had whooping cough, which she recalls almost dying from.  She lost a brother to the whooping cough (a twin of another brother).  Another brother died from croup at a just a few months old.  There were no vaccines at this point for them of course and routine visits to the doctor weren’t all that common unless there was a need.  Given the lack of antibiotics and vaccines back then, childhood was a journey with pitfalls not seen today that made it more of an accomplishment to get to adulthood than it is now.

When asked of her sleep habits she says, “now I’m sleeping all the time.  If I lay down at all I’m asleep!”  She says living as a young girl on the farm you were up early to do your chores and then get ready for school.  When you came home you started into the chores again.  There were three meals a day, breakfast and supper and home and lunch was taken to school.  Food eaten back then was grown on the farm.  Herring and codfish were also staples as were beef and pork from the farm.  Whole food was the norm. Processed and ultra-processed food we see today weren’t the food choice back then living on the farm.

Margaret isn’t one for social media, and as mentioned,growing up they had no phone.  They burned kerosene lamps for light at night.  Electricity wasn’t something she had in a home until she got married and moved out on her own.  One of the biggest differences between then and now was the direct social network everyone had.  There wasn’t a night in the winter regardless of how stormy it was, that there weren’t people over at the house.  Family or friends and neighbors would visit until 11:00 at night every night.  A common activity was playing cards and it wasn’t uncommon for visitors to travel with snowshoes back home.  Picturing what it would be like with no power or contact with the anyone (TV, cell phone, social media, email or texting) makes it more understandable how long evenings were passed with groups of visitors every day. She says there isn’t anything like this today.  In fact we have seen survival rates from some diseases like cancer have a better survival rate when the patient has a better direct social network available to them.  If there was a storm, there were no plows but for two days after the storm everyone would be out with their horse and sleighs making a path on the road.

One of her earliest recollections in the house was a day when her father was out working, perhaps out in the woods, and her mother was out doing chores outside of the house briefly at noon.  She was left in the house with her two older brothers, one of them being in charge while she was out.  She recalls it being a stormy day, her mother was out feeding the animals and when she came out of the barn she smelled smoke.  Looking in the direction of the house her mother saw smoke coming from the house and chimney.  Her father smoked and instead of using matches he would use long thin sticks to light his pipe that he lit in the fire.  Her babysitting brother found some of these laying around and grabbed one and put it in the fire.  There was an open chimney behind the stove with bark, kindling, and papers in it.  He threw the stick in the chimney causing everything in it to catch fire.  By the time her mother made it back to the house, her brother had taken the younger brother out of the high chair and ran with him into the bedroom off of the kitchen and closed the door, leaving Margaret crawling around on the floor.  When her mother got to Margaret she was almost to the blazing chimney.  Her mother had her hands full.  

Today only two sisters, Agnes (Baddeck) and Marion (Sydney) are still alive.  Marion’s daughter was raised for a while by Margaret’s mother when Marion went to Sydney to work, so she thinks of her as a sister.  Her siblings lived to be in their 70’s for the most part.  Her mother died 4 months shy of her 100^th birthday.  Margaret remembers her mother as being a hard working woman.  She wasn’t a nurse but she feels she could have been and would help deliver babies, was good around animals and people.  Her father passed away of a heart attack at 69 years of age.

In looking at what contributes to Margaret’s long life, we can certainly attribute her DNA passed down by her mother as being a major contributing factor.  There wasn’t a lot of money to go around the family growing up, but like the other families in the area they got through it.  Living on whole unpasteurized milk (not recommended today), curds, butter, cream, butter milk, vegetables and fresh farm raised meat.  Today she eats a little differently, margarine and 2% milk, and some processed food she might heat up in the microwave.  Aside from being forgetful with names, she is still quite active and comes into the pharmacy regularly.  A good sleep habit and regular physical activity are undoubtedly helping her to age in a healthy manner.  As a child and an adult, she had no cell phone to keep her up at night disrupting her sleep.  Finally, a strong network of other contacts that she regularly saw reflects the results we’ve seen in longevity from other studies.

Margaret has no major regrets looking back.  She supposes back growing up there were a lot of regrets of what she had to do but nothing lasting.  She recalls a story of two men in their 80’s for how she feels of this stage of life. One says to the other how great he feels and wakes up everyday wanting to take on the world.  The other one says he feels just the opposite.  He feels like a baby, “I have no hair, no teeth, and I just wet myself”.  Margaret also has a good sense of humor.

I’d like to thank Margaret for yet another down to earth talk with her and her willingness to share her experiences with everyone.  

Omega 3 supplements have been taking a beating lately with regard to cardiovascular outcomes. One thing that we have seen is the questionable cause and effect of the wide variety of commercially available Omega 3 supplements available on the market and the dose required for any effect at all.

Clinically, one indication I see Omega 3 supplements used for successfully is pain relief. It works along the same pathway as anti-inflammatory medications. But what does the evidence tell us about the effectiveness of such supplementation in an era where vitamins, herbs and supplements are more and more becoming a punching bag for quackery? Is there hard evidence for treating pain without the use of (oral) NSAIDS, opioids, muscle relaxers, antidepressants, counterirritant rubs, and anticonvulsants? Transdermal pain compounding comes to mind, but is there an OTC product you can start today in giving your customers to begin safely reducing their pain?

First of all you need to set expectations. If you are someone in chronic daily pain, you need to be upfront with them as a pharmacist by telling them that 100% pain relief is not a concept that we entertain. Your discussion with goal setting with them should inquire what they want to get out of this. Most patients in chronic pain don’t necessarily need to be pain free, they have learned for years how to live and cope with pain. What they may share with you is the desire to play with their grandkids, to go to church with their spouse, to go for a walk with their dog every day, or to just simply get out of bed and make a meal for themselves.

There have been a number of pain patients I can recall who have claimed that by taking this one supplement, they are able to do some of these activities. As evidence-based healthcare practitioners, we must strike a balance between following anecdotal evidence we’re presented with in the pharmacy and using the invaluable clinical evidence we see as healthcare professionals that really no one else sees. This balancing act inevitably involves stumbles where we fall for an N of 1 to strongly and apply it to everyone we speak to. In other moments of clarity, we look back at the results of our recommendations and accumulate a non-trial-based clinical judgment that we feel strong enough about to make recommendations for in the front store.

Recommendations to use Omega 3 supplementation in relieving pain are based on good quality evidence. When we look at the use of Omega 3 with rheumatoid arthritis (RA) specifically, it is important to reinforce with patients (and to ourselves as pharmacists) that this is not meant to replace what we use conventionally. Disease modifying antirheumatic drugs (DMARDS)should not be dropped in favor of Omega 3 supplementations. In fact DMARDS can help induce the remission of the disease when used early. They can, however, be used in conjunction with them.

Being a disease connected with the immune system, rheumatoid arthritis treatments that work with the body’s immune system are an attractive way to combat the problem. Omega 3 has been shown to affect our immune system. Arachidonic acid, which is an omega 6 product, flows into pathways that create inflammatory molecules which are involved in rheumatoid arthritis, including inside immune cells. The EPA and DHA in marine Omega 3 supplements reduces arachidonic acid. They follow a pathway which results in anti-inflammatory products and affects dentritic cell and T cell function. Additionally, it reduces reactive oxygen species by leukocytes and inflammatory cytokine production by macrophages. But the work on this area and how it pertains directly to RA is less understood. (1)

In a systemic review of 23 studies of Omega 3 use, modest but fairly consistent benefits were seen in relation to joint swelling, pain, the duration of morning stiffness, and the global assessments of pain and disease activity.(1)  There was also a benefit in the amount of NSAID therapy used in these patients.

In explaining just how omega 3 has a cause and effect relationship with RA and how studies show that it helps to reduce pain, we look to the similarity in effect between NSAIDS and Omega 3 in the body. Prostaglandin E2 (PGE2) is involved in all processes leading to the classic signs of inflammation (redness, heat, swelling, pain and edema). (2) A typical NSAID blocks the production of Eicosanoids including several prostaglandins as well as thromboxane proinflammatory products involved in pain and inflammation. Omega 3 reduces the production of mainly PGE2. Therefore you get the benefit of reduced pain and inflammation while avoiding the other problems with NSAIDS on the stomach. Unfortunately, the blood thinning still occurs, so those at risk for bleeding or on blood thinners need to be mindful of this. In reducing the dose of Omega 3 to avoid this, patients may put themselves in a dose range that is ineffective for RA. As you may have guessed, Omega 6 supplements increase arachidonic acid which is responsible for the production of these pro-inflammatory products, so combination 3-6 or 3-6-9 products are not recommended.

Based on current data, doses above 2.7g per day of combined Omega 3 ingredients in the fish oil are required for this response, which may be delayed for two to three months before results are fully realized.(3)

A systematic review that looked at the effect of marine fish oil on the pain of arthritic disease determined that it did in fact reduce pain in that population (4). An excellent source for references comes from the Australian NPS MedicineWise from April of this year. Over all it lays out a number of encouraging studies that can put another tool in the pharmacist’s toolbox for helping your RA patient.

Looking back to our “front store experience N of 1 world,” Omega 3 supplementation and joint pain relief always remind me of my 101-year-old customer who reminds me that she wouldn’t be moving at all without this supplement.

Graham MacKenzie is a compounding pharmacist in Baddeck, N.S., and a graduate of Dalhousie College of Pharmacy.

References

1. Miles EA, et al. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systemic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Supp; 2:171-84
2. Emanuela Ricciotti Et. al . Prostaglandins and Inflammation. Arterioscler Thromb Vasc Biol .2001 May; 31(5):986-1000
3. Rees D, et al Dose-related effects of eicosapentaenoic acid on innate immune function in healthy humans: a comparison of young and older men. Am J Cin Nutr. 2006 Feb;83(2):331-42
4. Senftleber NK et al Marine Oil Supplements for Arthritis Pain: A systematic Review and Meta_Analysis of Randomized Trials. Nutrients 2017.