The All-New Bunrab

Can you make a cake without sodium? Yes. First off, you DON'T need to add salt to make the cake rise. Many people think that yeast breads and quick breads/cakes won't rise if there's no salt. This is not true. The yeast in bread feeds off of sugar, not salt; salt just speeds it up a little. You can leave salt out of homemade bread willy-nilly. To me, it still tastes fine, but if you are going to be serving bread to people who aren't used to low-sodium cooking, you can do the following: Add a pinch (a spot about the size of the head of a nail) of regular salt to the bread, which is so much less than the recipes call for that the mgs of sodium will still be well under five mg per slice, and 2 pinches of potassium salt (such as NuSalt). You don't want to add more potassium salt for two reasons: (1) it tastes off to people who aren't used to it, and (2) normal people don't need that much potassium and it could even be problematic for them. So don't just substitute a teaspoon of NuSalt for a teaspoon of regular salt. You can also throw in a pinch of powdered ginger, along with your pinches of salt; the bread will not taste like ginger specifically, but it will taste a little less bland.

Back to cakes. Cakes don't use yeast; they use baking powder or baking soda to rise. Baking soda is sodium bicarbonate; baking powder is a mixture of baking soda, cream of tartar, and corn starch - still mostly baking soda, though. However, this is true mainly only in North America. In Europe, it is a lot more common to use baking powder made with calcium rather than with sodium. Calcium has many of the same properties as sodium - the three elements potassium, sodium, and calcium, are near each other on the table of chemical elements and all do similar things. This is why you'll see substitutes for salt involving potassium, and substitutes for baking powder involving potassium OR sodium. As I mentioned above, the substitutes involving potassium have to be used carefully, so that normal people don't get too much potassium; calcium doesn't cause that kind of concern. Most Americans don't get ENOUGH calcium in our diets, and may even benefit from the substitution of calcium-based baking powder instead of sodium-based.

The calcium baking powder most easily available in the USA is Rumford; it uses calcium phosphate instead of sodium bicarbonate. In my opinion, it's also an excellent baking powder; you are not going to lose anything in your baking by switching over to it. It does as good or better a job in cakes as regular baking powder. If your local supermarket doesn't carry Rumford, you can order it here. (Incidentally, according to their web site, Rumford also makes a cornbread mix that uses the calcium baking powder and is completely wheat-free as well.)

Another brand of sodium-free baking powder is Featherweight; it's available from Healthy Heart Market, whose link is to the right of this post. It is made of a mixture of monocalcium phosphate, potato starch, potassium bicarbonate. The potato starch gives it a very slightly different texture from corn starch, and in my opinion it does not rise as well as Rumford; you need to use a little bit more of it. If a recipe calls for a teaspoon of baking powder, try using between one-and-a-quarter teaspoons and one-and-a-half.

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And now for something completely different:
A few recent articles about heart failure; I've provided links, but in case you aren't a MedScape member, I've copied the abstracts as well, so you can get the gist of the articles.

The Role of Candesartan in the Treatment of Chronic Heart Failure
http://www.medscape.com/viewarticle/502413?src=mp

Hugh F. Mcintyre
From British Journal of Cardiology
Abstract
The renin-angiotensin system (RAS) plays a fundamental role in cardiovascular pathophysiology. In particular, angiotensin II (AII) has been identified as a culprit in endothelial and vascular damage, elevated blood pressure, and cardiac failure. Pharmacological inhibition of this system is available through two mechanisms; the reduction of AII formation by inhibition of angiotensin-converting enzyme (ACE), and by direct blockade of the type 1 angiotensin II receptor by angiotensin II receptor blockers (ARBs).

Angiotensin-converting enzyme (ACE) inhibitors have a proven role in the management of elevated blood pressure and diabetes and may confer specific vascular benefit. In patients with chronic heart failure (CHF) secondary to left ventricular systolic dysfunction (LVSD), there is extensive evidence that, when compared to placebo, ACE inhibitors reduce morbidity and mortality. Randomised placebo controlled trials have also shown ACE inhibitors reduce all-cause mortality and major cardiovascular events after myocardial infarction.

Given the unequivocal benefit of ACE inhibitors, initial studies with ARBs in patients with LV dysfunction (in CHF and following myocardial infarction) have focused on two areas: the role of ARBs when compared with ACE inhibitors, and when combined with ACE inhibitors.

Only recently, with the results of the CHARM study, have the role of ARBs when compared to placebo in a population with CHF been clarified. This study also addressed the benefit of ARBs in patients with heart failure and preserved LV systolic function.

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BNP Levels May Help Guide Carvedilol Therapy for Heart Failure
http://www.medscape.com/viewarticle/503627?src=mp
BY Megan Rauscher
NEW YORK (Reuters Health) Apr 20 - Carvedilol therapy is associated with a sustained decline in brain natriuretic peptide (BNP) levels in patients with congestive heart failure (CHF), research shows. This suggests, according to the investigators, that "serial BNP levels can provide some guidance" regarding the odds of carvedilol-driven improvement left ventricular function.

"Beta-blocker therapy improves symptoms, left ventricular ejection fraction, and survival in patients with CHF, but chronic effects on neurohormones have not been extensively investigated," Dr. Robert P. Frantz, from the Mayo Clinic in Rochester, Minnesota and colleagues explain in the March issue of the American Heart Journal.

They examined the relationship between clinical and echocardiographic parameters and serial neurohormones in 55 patients with CHF, most of whom had nonischemic dilated cardiomyopathy, treated with carvedilol over the course of 1 year. Forty-six patients completed 12 months of follow-up.

"We found that carvedilol therapy is usually associated with a decline in plasma BNP peptide levels," Dr. Frantz told Reuters Health. "The extent of change in BNP levels correlates with extent of change in left ventricular ejection fraction."

Specifically, at 12 months, left ventricular ejection fraction improved from 26% at baseline to 39%, and NYHA class improved from 2.3 to 1.8. BNP levels fell from 453 to 208 pg/mL at 6 months. Compared with baseline, levels remained significantly lower (233 pg/mL) at 12 months (p = 0.01).

"The relationship between changes in BNP levels and ejection fraction suggests that serial measurements of BNP may be a useful guide in monitoring patients with CHF who are being treated with carvedilol, but the relationship is not sufficiently strong to obviate the role for measurement of ejection fraction," Dr. Frantz said.

"If elevated BNP levels do not decline in a patient who is being treated chronically with carvedilol, it suggests that this patient may not have had improvement in ejection fraction and should be evaluated carefully," he added.

Am Heart J 2005;149:541-547.

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FDA Approvals: Hyzaar, Panzem, Decapinol
http://www.medscape.com/viewarticle/503708?src=mp

Yael Waknine

April 21, 2005 — The U.S. Food and Drug Administration (FDA) has approved a new indication for losartan potassium plus hydrochlorothiazide tablets, allowing their use to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy; an orphan drug indication for 2-methoxyestradiol capsules, allowing their use for the treatment of ovarian cancer; and an oral rinse with a barrier mechanism of action for the reduction of gingivitis in patients aged 12 years and older.

Losartan Plus Hydrochlorothiazide (Hyzaar) for Stroke Risk Reduction in Hypertensive Patients With LVH

On April 5, the FDA approved a new indication for losartan potassium plus hydrochlorothiazide (HCTZ) tablets (Hyzaar, made by Merck & Co.), allowing its use to reduce the risk of stroke in patients with hypertension (HTN) and left ventricular hypertrophy (LVH). There is evidence, however, that this benefit does not apply to black patients.

The indication was approved in March 2003 for losartan tablets (Cozaar, made by Merck & Co.), the angiotensin II receptor blocker component of the combination product.

Approval of the indication was based on the results of the landmark Losartan Intervention for Endpoint Reduction (LIFE) study in 9,193 patients, showing that a losartan-based regimen reduced the risk of fatal and nonfatal stroke by 25% in patients with HTN and LVH compared with atenolol-based therapy for a median follow-up period of 4.8 years (total number of strokes, 232 vs 309; P = .001).

Both regimens achieved similar reductions in blood pressure and no significant differences were observed between groups with respect to risk of myocardial infarction or cardiovascular death.

The extension of this indication to the losartan-HCTZ combination tablet was based on the frequency of HCTZ coadministration with the study drug to achieve target blood pressure in both groups of the LIFE trial (losartan, 73.9%; atenolol, 72.4%). In addition, the company demonstrated that the losartan and HCTZ tablets used in the trial were bioequivalent with the combination drug.

The FDA notes that in the LIFE trial black patients with HTN and LVH receiving losartan had a higher risk of stroke compared with those receiving atenolol. This finding has not been confirmed thus far because of the difficulty of interpreting subset differences in large clinical trials. However, trial data do not support use of losartan for the reduction of cardiovascular risk in hypertensive black patients with LVH.

Losartan potassium plus HCTZ fixed-dose combination tablets were previously approved for the treatment of HTN. Their use for initial therapy is only warranted in patients with severe HTN in whom the necessity of achieving prompt control of blood pressure outweighs the associated risks

One of the stitches on the incision for the pacemaker hasn't dissolved. I have some experience with pulling out stitches, but the location of the incision means I'd have to do it looking in a mirror, and I feel less confident about my ability to do that. It's a knotted end- it's not going to pull out painlessly, either. So I guess I'll have to call the doctor and get someone in his office to remove it.

I know how to remove stitches, and lots of other minor medical procedures, because I have pets. I work closely with my veterinarians' office in taking care of my pets, often assisting them directly, and certainly getting lots of stuff to take home for follow-up care. So I know how to lance, drain, and disinfect abcesses; how to remove stitches; how to give injections to a wide variety of species, including humans, and so on. Sometimes I think I have a rather peculiar range of skill sets for a computer teacher who used to be an accountant. (I still have my CPA license; I just don't do that for a living any more.)

Having a lot of odd hobbies is useful, in that social ties help people to stay healthier (a sample (article about this; there's lots more available). One study I read said that people who belong to six or more social groups live longer than people who don't belong to any. Apparently, social groups can be as formal as a workplace, a school, or a church, or as informal as the people who share your hobby and always seem to be in the store at the same time you are, be it fishing, knitting, or stamp collecting. Playing cards once a month with people counts. Belonging to a quilting bee counts. Joining your neighborhood association counts. I suspect even just being one of the regulars who goes to any and all free lectures offered by the public library counts; probably the librarians know the regulars, and the regulars know each other, and chat, maybe even have coffee together, afterwards. In my case, I belong to several animal rescue groups; hang out at a couple of stores that cater to my hobbies a lot; belong to my local Mensa chapter; belong to several church/state separation groups; and also have way too many relatives. (One of my sisters called last weekend- I now have 32 nieces and nephews. Welcome, Brenna Leigh.) So I think I can safely say I have at least six social groups. I hope that means more people who will notice if I seem to be getting worse, or if I start declining a lot of invites without apparent reason and will therefore worry about me. More people potentially available to drive me to doctor's appointments if I'm in bad shape. More people to send me links to new medical information on the net that may help me. Those things, I suspect, are some of the reasons people with social networks are healthier.

The heat really gets to me these days. I've never been fond of Texas summers; I moved down here 22 years ago, and still hate the weather. I'm even less fond of hot days now. The heat really makes me drag out my handicapped parking tag, because walking all the way across a parking lot seems way more than I can manage. I also am tired today, from doing some shopping. So this is a short day.

The question has no doubt occurred to you, does anyone make a no-sodium toothpaste? The answer, so far as I have been able to tell, is no. Besides sodium flouride, most toothpastes also have sodium saccharine, and sodium lauryl sulfate. Tom's of Maine has a couple of toothpastes, though, that contain only the last of these, no flouride or saccharine. First is their homeopathic-style toothpaste. Be sure to get the apricot flavor, not the baking soda flavor!! Baking soda is sodium! The apricot tastes a little odd to those used to minty commercial toothpastes, but you get used to it - that's what I'm using now. They also make a Natural Fluoride-Free Toothpaste which has no flouride or saccharine; don't order the peppermint or gingermint flavors, as those have baking soda in them. I have ordered the Cinnamint flavor, but haven't tried it yet.

So let's talk more about drugs. ACE inhibitors, for example. ACE stands for "angiotensin converting enzyme." What that actually is, is a relative of adrenaline, and it's a stimulant that makes your heart beat harder and your blood vessels tense up, for lack of another word. So an ACE inhibitor blocks the ACE, and thereby keeps your heart from being stimulated too strongly.

Now, the ACE inhibitors have a couple of drawbacks, although they are a vast improvement over many earlier hypertension drugs. Many earlier drugs caused impotence in many male users, for example. The ACE inhibitors usually don't. They do, however, cause a really severe cough in about 20% of the people who take them, a bad enough cough to make people have to stop using them. In women, this cough is severe enough to cause involuntary urine release - even in young women and women who do their Kegel exercises. Men get the cough, too, but generally don't have to worry about peeing in their pants when they cough. Some of the 'prils - that's another nickname for this class of drugs, because all the generic names end in "pril," such as enalapril, quinapril, and lisinopril - are less likely to cause this that others, but still somewhat. The Essential Guide (see Thursday's post) says that the cough is rare to infrequent; my family doctor, my cardiologist, and quite a few online sources say it's 20% of the people who take them, and I'm inclined to believe that estimate. The Guide says that this side effect is most common with delapril, least common with quinapril.

Now, for those who have the cough, one can switch to one of the newer Angiotensin-II Receptor Antagonist family, also referred to as Angiotensin II Inhibitors. The nickname for these drugs has not entirely settled yet; some doctors call them ACE-IIs, some A-II-B's (with II pronounced as "two"), and some call them ARBs. You could also refer to them as the 'sartans, because all the generic names end in sartan - candesartan, losartan, valsartan, etc. I take Diovan, which is valsartan. I am one of the people who got a severe cough from two different 'prils, before convincing my HMO to pay for the newer drugs. Some HMOs prefer the 'prils because some are available in generic now, whereas all the 'sartans are still brand-name only. If you have that cough, and really want to switch, here's one approach: tell your doctor that the cough (a) interferes with your ability to properly perform your job functions, and/or (b) interferes with your quality of life and your ability to normally perform some of your activities of daily living. Those are catch-phrases, that usually will have a positive result, because otherwise the HMO might be accused of discriminating against the disabled - that's where that "activities of daily living" phrase comes in.

According to the Essential Guide, one study found that two of the medicines in this family did not work as well in African Americans as other high blood pressure medications. A couple of specific studies have been done, with very positive results, on using this family of drugs for heart failure - losartan in particular, and eprosartan if used in conjunction with other drugs. My cardiologist tells me that it is expected that further studies will show that all the 'sartans have this effect to some degree, although possibly not all of them work as well as losartan. Losartan has been shown to decrease left ventricular hypertrophy (enlargement of the left ventricle). On the other hand, losartan should not be used by people with liver problems (and some people with severe heart failure do have liver problems as well), while the other 'sartans may need dosage adjustments but will not be compromised by liver problems.

Whew, is that a bunch of trivia about drugs, or what? And there's still the digitalis glycosides, the loop diuretics, the beta blockers, and the cholesterol-lowering statins to go!! Aren't you excited?

OK, I can't let a day go by without either a link or a recipe. Right? Well, one of the groups of foods that is high in potassium is dried fruit, such as dried apricots. My absolute favorite place to purchase dried fruit is Sweet Energy. They also sell candied ginger, a terrific snack that is fat-free and sodium-free, albeit a bit sugary - if you are trying one of those glycemic-index diets, candied ginger would be a no-no. I love the stuff; a small bit goes a long way because the flavor is so intense. They also make a granola that's not too high in fat (it does have coconut flakes and almond slivers in it, though), has no sodium, and is sweetened with maple syrup instead of sugar. It's yummy, but it's NOT low-calorie. They have regular internet-special sales; you can also order by phone or mail, if you prefer. They have a print catalog.

I had one of my regular visits with my cardiologist today. Because my ejection fraction hasn't improved, and I'm still frequently tired, he's decided to add spironolactone to my other prescriptions. I am already taking furosemide (generic of Lasix) as a diuretic, but spironolactone supposedly lets a person retain more potassium. I eat a lot of fresh fruit, so potassium hasn't been a noticeable problem- my blood levels are at the lower end of normal, but still within normal - but this diuretic supposedly works very well in conjunction with others. I of course immediately went to check my Pill Book and Essential Guide to Prescription Drugs. (If you follow those links to amazon.com, you will note that I have written reviews of both books.) The name of the drug is sort of funny - doesn't spironolactone sound more like some kind of blue-green algae than like a diuretic? Anyway, the books tell me that it's also an aldosterone antagonist, used for primary hyperaldosteronism (also known as Conn's Syndrome or Conn's Disease, usually caused by adrenal tumors or adrenal hyperplasia - information I found on the Web, not in these books). Anyway, the Pill Book tells me that in people with CHF, aldosterone levels can be 20 times higher than normal, causing water retention. Spironolactone helps the body release sodium and remove excess body fluids while retaining potassium. If you take spironolactone with an ACE inhibitor (more on those some other day), you actually wind up having to be careful of excess potassium, and get your blood levels checked frequently. I hope this doesn't mean I can't keep stuffing my face with melon and citrus fruits and kiwi fruit and even good ol' bananas. Also warns that this drug may increase digoxin levels. So, I have to go to the lab for bloodwork in 2 weeks, or sooner if I feel weirder than usual. Although potassium insufficiency (hypokalemia) frequently causes weakness and muscle cramps, apparently, according to The Pill Book, so do excessively high blood levels of potassium. Sheesh. Ya can't win.

The Essential Guide usually has longer and more thorough descriptions of the drugs it covers, although it covers fewer of them. It warns of more side effects for this drug than Pill Book does, including enlargement of male breast tissue and masculinization effects in women. I guess that is to be expected in something that affects hormones. (Aldosterone is one of the sex-related steroid hormones.) The Guide says that increased tolerance for walking and exercise can be expected from taking this drug. That is the goal, I suppose. In another few weeks, when I'm allowed to go swimming again (that healing pacemaker incision, you'll recall) it would be nice to have the energy to do so. I've gotten totally bored with yoga, and it's too d@mned hot to go walking. We'll see whether this works.

I found some really large cucumbers today, and an enormous parsnip, so one batch of summer pickles is more like two quarts this time than one quart. Emptied out the bottle of red wine vinegar and broke into the apple cider vinegar, even! Apart from their nice crunchy texture, the other reason to use parsnips in pickling is that saying "pickled parsnips" is so much fun!