Treating and Transcending Chronic Diseases

By George N. Saliba, Contributing Writer

While a stunning 60% of Americans suffer from chronic diseases, preventing and ameliorating these illnesses can often be aided by foundational wellness strategies including aerobic exercise, quality sleep, avoiding smoking, reducing stress, and consuming a Mediterranean diet replete with fruits and vegetables, whole grains, healthy fats and fish/lean meats. According to the peer-reviewed medical journal BMJ, US residents obtain nearly 60% of their daily caloric intake from ultra-processed foods, the latter of which are associated with 32 adverse health outcomes, including obesity. The Centers for Disease Control & Prevention (CDC) classifies more than 73% of Americans as overweight/obese, with 40.3% of these people clinically obese, meaning they have a Body Mass Index (BMI) greater than 30. In contrast, Japan’s population is just 4.9% obese in part due to a different cultural diet. 

Diabetes Type 2

It is, therefore, not necessarily surprising that more than 690,000 New Jerseyans, or 9.6% of the population, has been diagnosed with diabetes, and that an estimated additional 207,000 residents here have diabetes, but are unaware of it, according to the American Diabetes Association (ADA). The ADA also notes that 34% of New Jersey’s adult population has prediabetes, with blood glucose levels that are “higher than normal, but not yet high enough to be diagnosed with diabetes.”

For Naser E. Gharaibeh, MD, CPE, DABOM, NCMP, endocrinologist and obesity medicine consultant, metabolic medicine and weight loss director at Valley Health System, maintaining a healthy weight can aid patients, but health benefits can be achieved without a normal BMI/weight. He explains, “[For example,] someone [can have] a starting weight of 350 pounds, and have prediabetes or mild diabetes Type 2. If they lose 5% to 10% of their body weight, that gives them a clinically significant reduction in the risk of diabetes.” Gharaibeh underscores the importance of healthy cornerstones such as aerobic exercise, managing stress, obtaining enough sleep, consuming quality food, and limiting the intake of sugar and refined carbohydrates.

Non-insulin oral agents such as Metformin can also help control Type 2 diabetes, as can injectable medications including hormones which suppress appetite and slow the transfer of food from the stomach to the intestines. Separately, SGLT2 inhibitors can help patients excrete glucose through their urine. High-tech wearable glucose monitoring systems can additionally aid patients in tracking their blood pressure, heart rate, and heart rhythms.

Coronary Artery Disease (CAD) 

Heart disease is responsible for approximately 25% of all deaths in New Jersey, making it the leading cause of death here, even outpacing cancer deaths and fatal accidents. Prevention is key: The American Heart Association provides “Life’s Essential 8™” guidelines, which include managing blood pressure, managing blood sugar, controlling cholesterol, managing weight, getting healthy sleep, quitting tobacco, being more active, and eating better. 

“The biggest reversible single modifier for [coronary artery disease] is [stopping smoking],” explains Vasu M. Palli, DO, FACC, a cardiologist at Virtua Health, although the CDC reports that only 10.4% of New Jerseyans are smokers. Palli adds, “Insufficient sleep and sedentary lifestyle is becoming more and more of an issue as people work multiple jobs. Everyone’s running around trying to get ‘this and that’ done for deadlines.”

When lifestyle changes aren’t sufficient to manage coronary artery disease, statins are generally the first-line treatment for primarily four populations: Those who have had prior heart attacks, strokes, or peripheral vascular disease events; diabetics ages 40 to 75 with LDL (low-density lipoprotein) between 70 mg/dL and 189 mg/dL; patients whose LDL is greater than 190 mg/dL; and those who, in effect, fail a risk-factor calculator that accounts for ethnicity, blood pressure, and cholesterol. 

Patients with cardiac symptoms may undergo stress tests with imaging, echocardiograms, or be subjected to nuclear cardiology cameras or PET scanners. They may also undergo coronary CTAs, the latter involving searching for plaque by intravenously injecting dye into a patient to determine blood flow. When appropriate, patients may be referred to interventional cardiologists for coronary angioplasty with stent placement or other treatments.

Managing Cancer

Cancer is the second leading cause of death in the Garden State. Since there are hundreds of different types of cancers, each of those with dozens of separate cancer subtypes, the “most critical part, initially, is, obviously, getting the exact [cancer] diagnosis,” explains Andrew M. Evens, DO, MBA, MSc, deputy director for clinical services at Rutgers Cancer Institute, and medical director of the RWJBarnabas Health oncology service line. Once expert pathologists determine the precise diagnosis, biomarkers may help determine how to use targeted therapies, for which any given cancer there might be, say, six to eight different approved targeted therapies. 

Evens explains, “The true personalized therapy is: Can we use these biomarkers to identify the perfect treatment for the patient at the right time? There’s a lot of ongoing research and clinical studies that we’re happy to be involved with to truly identify personalized treatment for our patients.”

Early cancer detection is key. While there are no screenings available for most cancers, common cancers such as breast cancer, colon cancer, lung cancer and gynecologic cancers – to name a few – can be detected early and result in better outcomes. Evens concludes, “We want to catch the cancer before it is felt; before it is symptomatic.”

Rheumatoid Arthritis (RA)

Approximately 1.5 million Americans have rheumatoid arthritis, an autoimmune disease that may include swelling, pain, and soreness in joints. Patients may be treated with synthetic and biologic disease-modifying anti-rheumatic drugs (DMARDs), TNF blockers, JAK inhibitors, as well as other treatments such as physical therapy and cold treatments, for example. Sajina Prabhakaran, MBBS, MD, lead physician at Capital Health – Rheumatology Specialists, says, “We want to arrest the inflammation so that we can prevent ongoing damage to the body. That’s where the medications come in.”

In addition to prescribing medications, physicians advise against cigarette smoking and obesity. Consuming the aforementioned Mediterranean diet, remaining well hydrated, maintaining excellent gum/dental care, and reducing salt intake is also key for RA patients. Physical therapy and exercise are, again, vital, although Prabhakaran cautions: “You do not want to do active physical therapy or exercise on a joint that is inflamed. That will only lead to injury. But, as you’re doing your treatment and the inflammation is under control, the patient should slowly accelerate or increase their activity.”

Prabhakaran concludes, “Twenty years ago, we did not have [today’s] medications. Rheumatoid arthritis meant you would be in a wheelchair in 20 years. That’s how it was, because we didn’t have great treatment options. We had aspirin and cold [treatments], whereas now the treatment paradigm has changed. The odds that a patient will do well, and that they can have a full, fresh life, have gone up significantly … if [the patient] can be adherent [with their treatments].”

COPD

Induced by smoking and/or other damage to the lungs, chronic obstructive pulmonary disease (COPD) affects some 16 million Americans, and is the sixth leading cause of death in the US. “Just take care of your lungs, and they will take care of you,” advises Killol Patel, MD, director of interventional pulmonary, and medical director of the lung nodule and severe emphysema program at Hackensack Meridian Health, central region. “So, don’t smoke or do those things. I usually joke around with my patients that if you won’t expose a baby to something, then that’s what you should do, too … [such as] not taking [the baby] outside when it’s smokey.”

For those who develop COPD, it can be treated with short- or long-term acting bronchodilators, steroids, PDE4 inhibitors, lung volume reduction surgery, endobronchial valve placement, as well as lung transplants.

Multiple Sclerosis (MS) 

Multiple sclerosis (MS) is a chronic disease impacting the central nervous system, causing damage to the myelin sheath that protects nerve cells. Although the exact cause of MS is unknown, it is often thought that MS may develop when a genetically susceptible person is exposed to environmental factors such as low vitamin D levels, insufficient sleep, smoking, high-salt diets, chronic stress, obesity, and, in particular, Epstein-Barr virus. An MS diagnosis can be made by ruling out other neurological disorders and by leveraging MRIs, cerebral spinal fluid analysis, noting patient symptoms, and through blood tests, for example. 

In addition to improving the above-listed patient lifestyle factors – and exercising and maintaining mental cognition – Mary Ann Picone, MD, medical director at Holy Name Medical Center’s “The MS Center at Holy Name” says, “Years ago, there was this saying that if someone was diagnosed with MS, it unfortunately was sort of like ‘diagnose and adios.’ There wasn’t much that we could do [for a patient with MS]. It’s really been just since 1993 that there were any effective therapies for the disease, and they’ve certainly gotten better in terms of efficacy, over the years. We have infusion treatments, injectable medications – which were the first treatments that came out – and oral medications.”

Chronic Renal Disease

The CDC reports that 14.6% of Americans have chronic renal (kidney) disease (CKD), and controlling one’s blood pressure, consuming a low-salt diet, avoiding nonsteroidal anti-inflammatory drugs (NSAIDs), and engaging in aerobic exercise can aid in its prevention and treatment. 

John Saldarini, MD, associate system medical director of nephrology for Atlantic Health System, says that the biggest contributors to chronic kidney disease are diabetes, high blood pressure, and obesity. He says, “When you take into account that the vast majority of adults [with] CKD have one or more of those conditions, then all of the lifestyle factors [listed above] are spot on: Aerobic exercise doesn’t necessarily prevent chronic kidney disease, but it does decrease your risk of having high blood pressure, and it helps prevent obesity, so it has benefits in indirect ways.” 

He underscores: “The vast majority of people who have [CKD] don’t know they have it, so their diagnosis is simple: It’s a blood test and urine test. … You can think of the blood test as [sort of a] percent function: At what percentage are the kidneys functioning? If you fall below a certain level, we’ve categorized that as having kidney disease.” 

Various iterations of medications and/or dialysis can treat patients with kidney disease, but gold-standard kidney transplants are harder to obtain: In New Jersey, the waitlist for a deceased donor transplant is between five and seven years. That said, live donations are more popular now and are not limited to family members; daisy-chain donation programs with compatible families/donors are possible. 

Saldarini encourages patients to get screened early on for CKD via their primary care physicians. He says, “The earlier we screen you and the earlier we catch it, the more we can do. It does not have to be the case that any individual with chronic kidney disease invariably winds up on dialysis. In fact, the vast majority do not, and we can slow that progression very effectively with the tools we have.”

Irritable Bowel Syndrome (IBS) 

While the exact causes of irritable bowel syndrome (IBS) – which includes symptoms such as abdominal pain, bloating, and changes in bowel movements – are not clear, there is an association with dysmotility in the intestines, changes in gut microbes, and childhood trauma; IBS can also develop following severe diarrhea from bacteria or a virus. 

“I would really broaden [the scenario] to what is now being labeled as the gut-brain access, or some degree of neurohormonal dysregulation that happens in certain individuals,” says Arkady Broder, MD, FACG, FASGE chief, division of gastroenterology and hepatology; program director, gastroenterology fellowship; and director of the endoscopy unit at Saint Peter’s University Hospital. 

Patients with IBS-type symptoms may be diagnosed according to certain criteria, or they may require colonoscopies, upper endoscopies, blood tests, stool tests and hydrogen breath tests to obtain a correct diagnosis or to rule out more serious conditions such as colon cancer.

IBS patients are often advised to increase their fiber intake, refrain from dairy products, avoid gluten, maintain hydration, undergo relaxation techniques, ensure proper sleep, undertake physical exercise, and engage is psychotherapy treatments; low doses of antidepressants may also be appropriate. Broder cautions, however: “There’s no one-size-fits-all; it’s a very individualized treatment process.” 

Mental Illness

The National Institute of Mental Health (NIMH) estimates that more than one in five US adults lives with a mental illness, and that conditions vary in degree of severity, ranging from mild to moderate to severe. Englewood Health’s Magdalena Spariosu, MD, says that patients are admitted for inpatient psychiatric care for many reasons, including severe depression, manic episodes, psychosis, debilitating anxiety, and neurocognitive disorders with mood or behavioral disturbances. She adds that admission is also indicated when there is a risk of harm to oneself or others, or when patients are unable to function due to overwhelming psychiatric symptoms.

Spariosu says treatment for these patients can be multidisciplinary: Medication management, individual and group psychotherapy, activity therapy, stress reduction techniques, and education about healthier lifestyle choices all can play a role. 

Treatment is also available for outpatients, with Spariosu saying, “At Englewood Health, we see a wide spectrum of patients in our outpatient services, ranging from those with common mood and anxiety disorders to individuals managing more complex conditions like schizophrenia or substance use disorders.”

Conclusion

Chronic diseases are often preventable or treatable via core lifestyle modifications, and/or in tandem with leading-edge biopharmaceuticals and other advanced treatments. Given that the US has the most chronically ill population in the world, New Jerseyans and Americans overall have enormous opportunities to improve their health by changing their life habits, statistically decreasing the probability they will have to rely upon healthcare facilities for complex treatments.

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