Is HRT Safe?

1.    Background to the issue – the basis of hormone therapy (HRT)

2.    Current thinking on HRT:

·       What the science and scientists say – is HRT right for you?

·       Scientific studies:  -    Million Women Study (MWS) – a UK study

-        Women’s Health Initiative (WHI) – a US study

3.    The complexity of HRT risk and NICE guidelines on HRT prescribing

4.    Summary - is HRTsafe?

5.    What are the natural alternatives to HRT?

Background to the issue

 Early 1990s – large scale studies were set up.

 HRT widely prescribed for:

• relieving menopausal symptoms
• preventing osteoporosis
• preventing heart disease (not all studies confirmed its benefits)

Q. where does the evidence come from? 

 ·       WHI (Women’s Health Initiative) Hormone Replacement Study

 American trials designed to study CV risk

 ·       MWS (Million Women Study)

A UK Study designed to investigate the risk of breast cancer in women using different types of HRT

Findings from these studies (2002)

1.    Little to no evidence if reduced risk of heart disease. In fact, there was evidence for an increased risk of blood clots and stroke.

2.    Increased risk of breast and ovarian cancer

3.    Most of the effects of HRT (positive and negative) are seen whilst taking HRT and disappear once HRT is stopped.

The WHI study was abruptly halted.

Q. what are the more recent findings?

An 18-year follow-up study of the participants in the WHI study provides more reassurance:

·       no greater risk of dying in the subsequent 18 years that not for those on HRT

·       Risks of all-cause mortality, CV mortality or cancer mortality is NOT associated with HRT

Analysis of the WHI study data focussed on the age of the participants. The findings show that:

·       older women were at high risk

·       benefits outweighed the risks:

a.     for healthy women ˂ 60 years

b.    within 10 years of onset of the menopause

·       women who started HRT in early menopause tended to live longer than women who didn’t take HRT (observational study evidence)

Evidence from 30 clinical trials show that:

women who began HRT before 60 years had 39% lower risk of death than women who didn’t take HRT (pooled statistical analysis)

Newer formulations* of hormones (since the WHI study began) may further minimise the risks.

*Newer formulations include:

·       transdermal oestrogen (patches)

·       micronized progesterone

·       SSRIs (typically prescribed as antidepressants) relieve hot flushes and other menopausal symptoms

The complexity of HRT risk (MWS data)

·       breast cancer risk is a good example of this complexity

·       risk is greater for combined HRT (oestrogen-progesterone) than oestrogen-only HRT

·       risks are greater:

-        for combined HRT than oestrogen-only HRT

-        when HRT is started around the time of the menopause rather than later

-        for thinner than fatter women (BMI is a consideration) because oestrogen is a fat-soluble hormone so fatter women produce more oestrogen and adding extra oestrogen makes less of a difference compared to thinner women who have less fat to absorb circulating oestrogen)

·       HRT-associated risks for breast cancer ranged from over two-fold increased risk to no added risk depended on:

a.     type of HRT

b.    timing of use

c.     BMI

·       Differing patterns of association with different forms of HRT on:

a.     heart disease

b.    stroke

c.     fractures

d.    ovarian cancer

 41% of UK medical schools do not have mandatory menopause education on the curriculum. Many UK universities expect their students to gain menopause education whilst on their GP training placements:

• this is a risky practice because it relies entirely on whether the GP trainer is knowledgeable about menopause and HRT advice
• many GPs have little or no formal menopause education and not familiar with current guidance.

The Verdict: HRT isn’t all bad… nor all good. There are benefits as well as risks.

Benefits	Risks
Relieve symptoms to allow women to function in their day-to-day lives	Benefits usually outweigh the risks
Relief of unpleasant symptoms such as: ·       hot flushes ·       night sweats ·       mood swings ·       vaginal dryness ·       ↓ sex drive	HRT is a medicine and comes with SE. Specific SE of oestrogen and progesterone (see table)
Prevent osteoporosis	Other risks: ·       breast cancer ·       blood clots ·       heart disease ·       strokes

Most of the effects (benefits and risks) are seen while women are on HRT, then disappear once HRT is stopped). Risks only persist as long as HRT is taken.

 No hysterectomy (uterus present):

R_x oestrogen + progesterone (or progestin*) since progesterone is needed to balance the effects of oestrogen otherwise the oestrogen can stimulate the growth of the uterine lining (endometrium) and ↑ the risk of endometrial/uterine cancer

*progestin = synthetic progesterone (progesterone-receptor agonists)

Hysterectomy (uterus absent):

Rx oestrogen only

Recommendations:

·       find the best product and delivery method that best suits each person

·       minimise the amount of HRT taken (lowest possible dose)

·       seek regular follow up care

·       make healthy lifestyle choices

Weaning off HRT

Gradually decreasing your HRT dose is usually recommended because it's less likely to cause your symptoms to come back in the short term.

Side effects of oestrogen	Side effects of progestogen
The main side effects of taking oestrogen include: bloating breast tenderness or swelling swelling in other parts of the body feeling sick leg cramps headaches indigestion vaginal bleeding	The main side effects of taking progestogen include: breast tenderness swelling in other parts of the body headaches or migraines mood swings depression acne tummy (abdominal) pain back pain vaginal bleeding
Any side effects usually improve over time, so it's a good idea to persevere with treatment for at least 3 months if possible. These side effects will often pass after a few weeks. To ease side effects, try: taking your oestrogen dose with food, which may help feelings of sickness and indigestion eating a low-fat, high-carbohydrate diet, which may reduce breast tenderness doing regular exercise and stretching, to help leg cramps	As with side effects of oestrogen, these will usually pass after a few weeks.   If they persist, a GP may recommend switching to a different way of taking progestogen, changing the medicine you're taking, or lowering your dose.

NICE Guidelines for Prescribing HRT (2015)

• contraindications and cautions
• routes of administration
• choice of hormone
• regimen (perimenopausal + menopausal women)
• adverse effects

Women’s Health and the NHS

·      Responses from 100,000 women surveyed (call to collect views made in Spring 2021)

·       Part of a wider ‘women’s health strategy’

·       More needs to be done to close the ‘gender gap’ in NHS services

·       Sexism/gender inequality blamed for failings around prescribing of HRT

·       Other inequalities around:

-        postcode lottery for IVF

-        disproportionate ↑ in gynaecological waiting lists

-        failings in HRT prescribing

-        treatment failings in endometriosis

Q. So what are the alternatives?

1. Herbal Medicine (instead of HRT, specific herbs/phyto-oestrogens, holistic management address other symptoms
2. Massage Therapy especially stress management and sleep
3. Practical Measures (Holistic Management):

·       clothing (layering up)

·       stress management techniques (eg. yoga, tai-chi, massage, meditation etc..)

·       EOs or wax melts

·       connecting with nature (eg. gardening, walking in woodland/open spaces etc…)

·       counselling

·       diet (↓caffeine, ↓alcohol, ↑fermented foods)

·       exercise (↑resistance training to improve bone/joint health)

Plant-Based Meats, Human Health, and Climate Change

There is wide scale concern about the effects of red meat on human health and climate change. Plant-based meat alternatives, designed to mimic the sensory experience and nutritional value of red meat, have recently been introduced into consumer markets. Plant-based meats are marketed under the premise of environmental and human health benefits and are aimed appeal to a broad consumer base. 

Meat production is criticised for its overuse of water supplies, landscape degradation, and greenhouse gas emission, and depending on production practices, environmental footprints may be lower with plant-based meat alternatives. Life-cycle analyses suggest that the novel plant-based meat alternatives have an environmental footprint that may be lower than beef finished in feedlots, but higher than beef raised on well-managed pastures. This post discusses the nutritional and ecological impacts of eating plant-based meat alternatives vs. animal meats. 

Most humans generally follow an omnivorous diet: they satisfy some nutrient requirements better from plant foods, while needs for other nutrients are met more readily from animal foods. Animal foods also facilitate the uptake of several plant-derived nutrients (zinc and iron), while plant nutrients can offer protection against potentially harmful compounds in cooked meat. Thus, plant and animal foods operate in symbiotic ways to improve human health. The mimicking of animal foods using isolated plant proteins, fats, vitamins, and minerals likely underestimates the true nutritional complexity of whole foods in their natural state, which contain hundreds to thousands of nutrients that impact human health. 

Novel plant-based meat alternatives should arguably be treated as meat alternatives in terms of sensory experience, but not as true meat replacements in terms of nutrition. If consumers wish to replace some of their meat with plant-based alternatives in the diet (a “flexitarian approach”) this is unlikely to negatively impact their overall nutrient status, but this also depends on what other foods are in their diet and the life stage of the individual.

Fortifying Foods to Mimic the Natural Food Source

A recurring concern is that natural whole foods are extremely complex and the reductionist approach of trying to “mimic” whole food sources (whether it be meat or other foods) by combining several isolated nutrients likely underestimates the true complexity and health benefits of eating whole foods. In particular, fortification of a low-meat diet with zinc and other minerals found in meat did not result in similar zinc status as when these minerals were provided in the diet as part of the natural matrix of meat. 

Moreover, adequate intakes of zinc, copper, and vitamins A and D were associated with decreased risk of cardiovascular disease and all-cause mortality when obtained from foods, but not from supplements, in a recent large population-based study. Similarly, carotenoid-containing foods are associated with a decreased risk of various cancers, retinopathies, and cardiovascular disease. However, the results of interventional and epidemiological studies suggest that carotenoid and/or vitamin A supplements do not decrease the risk of cancer or cardiovascular disease and might even raise the risk for some sub-populations. 

Similar findings have been made in studies of calcium that show a potential for increased cardiovascular disease risk with supplementation but not when calcium is obtained from food. Finally, similar findings have been made for vitamin C and selenium supplements that show no benefits on mortality in a systematic review of randomised controlled trials (RCTs) comprised of nearly 300,000 individuals. Thus, it appears that simply ingesting these nutrients outside of their natural food matrices may not be an optimal solution for promoting health. Thus, obtaining nutrients from whole food sources as opposed to supplemental forms is emphasised regardless of the individual's diet.

The Ecological Impacts of Plant-Based Meat vs. Meat Consumption

The plant vs. meat controversy takes on other dimensions when assessing environmental degradation and climate change, both of which adversely affect human health and are crucial considerations when making recommendations on diets for livestock and humans. Meeting requirements of nutrients with plant foods (e.g., folate, manganese, thiamine, copper, and β-carotene) may come at a lower environmental footprint (i.e., less greenhouse gas emissions or GHGEs) than when these nutrients are met with animal foods. Nonetheless, it has been suggested that similar amounts of protein, iron, and vitamin A can be obtained from carefully selected plant-based diet at a lower carbon footprint when compared to omnivorous diets/animal foods.

The lower carbon footprint of plant-based meat alternatives is touted as a main reason for choosing plant alternatives over beef. While meat alternatives may have a lower environmental impact when compared to feedlot-finished beef, well-managed pasture-based livestock systems fix at a minimum all the GHG they emit (and sometimes more) even when considering all aspects of the production. Pastured beef systems that use land management practices such as rotational grazing—where lands are allowed to properly recover after a grazing period—and/or cover crop grazing suggest that the amounts of carbon sequestered in the soil more than offsets the ruminants' GHGE, resulting in a net negative carbon footprint. By having livestock participate in carbon cycling by spending their lives on well-managed pastures—grooming and fertilising vegetation and soil—such production systems have the potential to help mitigate climate change (or in the very least not exacerbate it further) while ensuring a degree of food security.

Well-managed grasslands, especially in more mesic (moisture-rich) areas, can act as carbon sinks in a variety of geographical locations worldwide and depending on geographical locations, may be more reliable carbon sinks than forest. It must be noted that the two (forests and livestock) are not mutually exclusive to begin with, as demonstrated by successful implementation of silvopastoralism—a type of agroforestry integrating trees, forage, and livestock—in forested areas across the globe as a strategy to enhance carbon sequestration, soil health, and food security for those inhabiting such areas. Thus, considerations regarding livestock-production systems should be tailored to fit the geophysical landscape instead of attempting—often at great expense—to change the environment to fit the production system. For example, it would be suitable to practice silvopasture techniques with locally adapted animals in landscapes such as the Amazon rather than attempting to convert its forests to pasturelands.

It must be noted though that not all pasture-based (grass-fed) operations are per se regenerative or neutral, and depending on management practices, grass-fed beef systems can have a higher carbon footprint than some feedlot systems. It is also important to highlight that the amount of carbon sequestered with well-managed grazing of livestock on carbon-depleted soils is initially more rapid and diminishes over time as soil health is restored, which is not surprising once equilibrium of ecological systems are reached.

The ecological impacts of human diets are not as simple as plant vs. meat discussions might suggest. The global food system is far too diverse and contingent on unique environmental and socioeconomic circumstances to allow for one-size-fits-all policy recommendations. As the latest IPCC (Intergovernmental Panel on Climate Change) Report points out, mixed plant farming-livestock grazing systems can heal damage done by years of continuous arable cropping reliant on mechanical and chemical inputs. In the process, we may increase the number of animals grazing phytochemically rich landscapes that nurture animals, soil, plants, and people, and provide food that is biochemically richer and arguably more nourishing for Homo sapiens and the planet.

Conclusion

Humans satisfy requirements for certain nutrients much better from plant foods, while needs for other nutrients are met more readily from animal foods. Plant nutrients (i.e., phytochemicals) often protect against potentially harmful compounds in cooked animal foods while animal foods also facilitate the uptake of several plant nutrients (e.g., zinc and non-haem iron). Thus, plant and animal foods interact in symbiotic ways to improve human health.

While plant-based diets are being promoted for human and environmental health reasons, this may put large portions of the population at greater risk for nutrient deficiencies and accompanying health issues. This may especially be the case for vulnerable populations such as children, elderly, and nursing mothers who are at increased risk for nutritional deficiencies. Some suggest that in order to meet requirements for several key nutrients with plant foods (vitamins A, B3,6,12, choline, zinc, iron, and selenium), more plants should be ingested to overcome their reduced bioavailability and supplements should be taken if deficiencies arise (vitamin B12 would have to be supplemented regardless). However, intra-individual differences in nutrient metabolism may preclude portions of the population to thrive on vegan/vegetarian diets, regardless of how well the plant-based food or diet may be “designed.”

Many scientists are concerned about the reductionist approach of simply adding isolated forms protein, vitamins, and minerals to foods, or diets in general, and designating them as nutritionally adequate. As whole foods contain hundreds-to-thousands of compounds that act synergistically to impact human health, adding synthetic nutrients to food sources often does not confer similar benefits compared to when these nutrients are ingested as phytochemically and biochemically-rich whole foods—whether it be plant or animal foods.

Scientists who operate in the realms of nutrition and ecology, those in companies that produce plant-based meat alternatives, and the general public arguably share similar concerns about the influence of agriculture on climate change. Where groups differ is in their solution to the challenge. There are many whole-foods dietary options that could substantially improve human and ecological health - whether they be vegetarian, pescatarian, or omnivorous. An omnivorous diet rich in whole foods, produced using sustainable agricultural practices that integrates plants and animals in agroecological ways (i.e., in harmony with natural systems), is most likely to benefit human and ecological health.

At present, novel plant-based meat alternatives should arguably be treated as meat alternatives in terms of sensory experience, but not per se as true nutritional replacement for meat. If consumers wish to replace some meat in their diet with plant-based alternatives (a “flexitarian approach”), this is unlikely to negatively impact their overall nutrient status; however, this also depends on what other foods are routinely consumed and the life stage of the individual (e.g., infancy, pregnancy, or advancing age). That said, it is important for future work to compare human health outcomes in response plant-based vs. animal meat consumption. Such studies can ensure, and potentially improve, the healthfulness of plant-based meat alternatives and meat itself, as it is likely that both will have a have a significant role to play in our future food supply.

Reference

van Vliet S, Kronberg SL and Provenza FD (2020) Plant-Based Meats, Human Health, and Climate Change. Front. Sustain. Food Syst. 4:128. doi:  0.3389/fsufs.2020.00128

Are soy products are adequate substitutes for meat and dairy products?

It is typical for vegans and vegetarians in the Western world to rely on various soy products for their protein needs. There is little doubt that the billion-dollar soy industry has profited immensely from the anti-cholesterol, anti-meat gospel of current nutritional thought. Whereas, not so long ago, soy was an Asian food primarily used as a condiment, now a variety of processed soy products proliferate in the North American market. While the traditionally fermented soy foods of miso, tamari, tempeh and natto are definitely healthful in measured amounts, the hyper-processed soy “foods” that most vegetarians consume are not.

Non-fermented soybeans and foods made with them are high in phytic acid, an anti-nutrient that binds to minerals in the digestive tract and carries them out of the body. Vegetarians are known for their tendencies to mineral deficiencies, especially of zinc and it is the high phytate content of grain and legume based diets that is to blame. Though several traditional food preparation techniques such as soaking, sprouting, and fermenting can significantly reduce the phytate content of grains and legumes, such methods are not commonly known about or used by modern peoples, including vegetarians. This places them (and others who eat a diet rich in whole grains) at a greater risk for mineral deficiencies.

Processed soy foods are also rich in trypsin inhibitors, which hinder protein digestion. Textured vegetable protein (TVP), soy “milk” and soy protein powders, popular vegetarian meat and milk substitutes, are entirely fragmented foods made by treating soybeans with high heat and various alkaline washes to extract the beans’ fat content or to neutralise their potent enzyme inhibitors. These practices completely denature the beans’ protein content, rendering it very hard to digest. Monosodium glutamate (MSG), a popular and widespread flavouring, a known neurotoxin, is routinely added to TVP to make it taste like the various foods it imitates.

On a purely nutritional level, soybeans, like all legumes, are deficient in cysteine and methionine, vital sulphur-containing amino acids, as well as tryptophan, another essential amino acid. Furthermore, soybeans contain no vitamins A or D, required by the body to assimilate and utilise the beans’ proteins. It is probably for this reason that Asian cultures that do consume soybeans usually combine them with fish or fish broths (abundant in fat-soluble vitamins) or other fatty foods.

Parents who feed their children soy-based formula should be aware of its extremely high phytoestrogen content. Some scientists have estimated a child being fed soy formula is ingesting the hormonal equivalent of five birth control pills a day. Such a high intake could have disastrous results. Soy formula also contains no cholesterol, vital for brain and nervous system development.

Though research is still ongoing, some recent studies have indicated that soy’s phytoestrogens could be causative factors in some forms of breast cancer, penile birth defects and infantile leukaemia. Regardless, soy’s phytoestrogens, or isoflavones, have been definitely shown to depress thyroid function and to cause infertility in every animal species studied so far. Clearly, modern soy products and isolated isoflavone supplements are not healthy foods for vegetarians, vegans, or anyone else, yet these are the very ones that are most consumed.

Ref: https://www.yumpu.com/en/document/read/42914559/the-myths-of-vegetarianism-stephen-byrnes-phd