Monthly Archives: January 2012

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IBS, a frustrating medical condition, shows improvement for some with lifestyle modifications

It seems like I have more and more patients who suffer from irritable bowel syndrome. IBS can be a very frustrating disease for both the patient and the physician.

The perception is that the symptoms are somewhat vague. They include cramping, abdominal pain, bloating, constipation and diarrhea, according to the National Digestive Diseases Information Clearinghouse, a division of the National Institutes of Health. Some patients have more of one type of bowel movement, diarrhea or constipation, than the other.

Physicians use the Rome III criteria (an international effort to create scientific data to help in the diagnosis and treatment of functional gastrointestinal disorders) and careful history and physical exam for diagnosis. However, there is not a specific medicine for this disease, though some have shown benefits.
I think what epitomizes IBS is the colonoscopy study, which shows IBS patients who underwent colonoscopy where diagnostic findings were nil, tends to frustrate patients even more, not reduce their worrying, as the study authors had hoped (Gastrointest Endosc. 2005 Dec;62(6):892-899).

Rather, it plays into that idea that patients don’t have diagnostic signs, like in inflammatory bowel disease, yet their morbidity (sickness) has a profound effect on their quality of life. Socially, it is difficult and embarrassing to admit having IBS. Plus, with a potential psychosomatic component, it leaves patients wondering if it’s “all in their heads.” IBS is also a considerable financial burden on the healthcare system (Scand J Gastroenterol. 2006;41:892-902).

To boot, this disease is very common, affecting about 20 percent of the population, according to the NDDIC. For inflammatory bowel disease patients, there’s an even higher prevalence, with 30 to 35 percent of this population affected (Curr Treat Options Gastroenterol. 2005;8:211-221).
So, what can be done to improve IBS? There are a number of possibilities to consider.

The brain-gut connection

The “brain-gut” connection, which is also known as mindfulness-based stress reduction, was used in a study with IBS. Those in the mindfulness group (treatment group) showed statistically significant results right after training and three months post-therapy in decreased severity of symptoms compared to the control group.

Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.
This was a small but randomized clinical trial, the gold standard of studies, which was eight weeks in duration (Am J Gastroenterol. 2011 Sep;106(9):1678-1688).

Gluten effect

In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo (68 percent vs. 40 percent, respectively).

These results were highly statistically significant (Am J Gastroenterol. 2011 Mar;106(3):508-514). The authors concluded that nonceliac gluten intolerance may exist. Gluten sensitivity may be an important factor in the pathogenesis of a portion of IBS patients (Am J Gastroenterol. 2011 Mar;106(3):516-518).

I suggest to my patients that they might want to start out by avoiding gluten and then add it back into their diets to see the results. Foods containing gluten include anything made with wheat, rye and barley.

What about fructose?

Some IBS patients may suffer from fructose intolerance. In a prospective (forward-looking) study, IBS patients were tested for this with a breath test. The results showed a dose-dependent response. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.

The symptoms of fructose intolerance included flatus, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that avoidance of fructose may reduce symptoms in IBS patients (Am J Gastroenterol. 2003 June;98(6):1348-1353).

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (J Clin Gastroenterol. 2008 Mar;42(3):233-238). This change has only a small impact on lifestyle compared to full-blown symptoms of IBS.

Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.

Does lactose play a role?

In another small study, about one-quarter of patients with IBS also turn out to have lactose intolerance. Two things are at play here. One, it is very difficult to differentiate the symptoms of lactose intolerance and IBS. The other is, if you couldn’t already surmise, most of the trials in IBS are small and there is a need for larger trials.

Of the IBS patients that were also lactose intolerant, there was a marked improvement in symptomatology at both six weeks and five years when placed on a lactose-restrictive diet (Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944).

Though the trial is small, the results were statistical significant, which is impressive. Both the durability and the compliance were excellent. Visits to the outpatient clinics were reduced by 75 percent. When appropriate, a lactose-restrictive diet is cost effective and a time savings according to the authors. This demonstrates that it is most probably worthwhile to test patients for lactose intolerance who have IBS.

Why might medications be relevant?

There may be small intestine bacteria overgrowth in IBS patients. In a newly published trial using an upper gastrointestinal scope, 37.4 percent of IBS patients had SIBO (Dig Dis Sci. 2012 Jan 20). Interestingly, SIBO was found in 60 percent of IBS patients with predominantly diarrhea symptoms compared to only 27.3 percent without diarrhea symptoms. This was a statistically significant difference.

The organisms found most commonly in SIBO were E. coli, Enterococcus and Klebsiella pneumoniae. The authors suggest that this study reinforces clinical trials demonstrating a therapeutic role of nonabsorbable antibiotics in the treatment of IBS patients with small intestinal overgrowth.

What about probiotics?

Treatment with probiotics from a study that reviewed 42 trials shows that there may be a benefit to probiotics, but the endpoints were different in each trial.

The good news is that most of the trials reached one of their endpoints (Aliment Pharmacol Ther. 2012 Feb;35(4):403-413). Unfortunately, there were variations in magnitude of effect and choice of outcome.

Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in this review.

All of the above gives IBS patients a sense of hope that there are options for treatments that involve modest lifestyle changes and that may or may not include medications. I believe there needs to be a strong patient-doctor connection in order to choose the appropriate options that result in the greatest reduction in symptoms.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website and/or consult your personal physician.

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It is now mid-January, and most of us have made a New Year’s resolution. You’ve taken the first step, but how do you increase the “stickiness factor,” a term used by Malcolm Gladwell in his book, “The Tipping Point: How Little Things Make a Big Difference.”

Setting a goal that is simple and singular helps.  We often overdo it by focusing on multiple resolutions on a host of topics, like being organized, working more efficiently and improving health. While these are all admirable, multiple large goals diminish your chances of success. Instead, your goal might be to improve health by losing weight and reversing disease.

Changing habits is always hard. There are some things that you can do to make it easier, though.


Your environment is very important.  According to Dr. David Katz,  director, Yale-Griffin Prevention Research Center, it is not as much about willpower as it is about your environment. He wrote about this subject in the Huffington Post on Jan. 4 in response to Tara Parker-Pope’s Jan. 1, New York Times Magazine article about weight loss.

Willpower, Dr. Katz writes, is analogous to holding your breath underwater — it is only effective for a short time frame. Thus, he suggests laying the groundwork by altering your environment to make it conducive to attaining your goals. Recognizing your obstacles and making plans to avoid or overcome them reduces stress and strain on your willpower.

According to a recent study, people with the most self-control utilize the least amount of willpower, since they take a proactive role in minimizing temptation (J Pers Soc Psychol. 2012;102:22-31). Start by changing the environment in your kitchen. I touched on the importance of environment in my Nov. 25, 2010, article.

Support is another critical element.  It can come from within, but it is best when reinforced by family members, friends and co-workers. In my practice, I find that patients who are most successful with lifestyle changes are those where household members are encouraging or, even better, when they participate in at least some portion of the intervention, such as eating the same meals.

Automaticity: Forming new habits

When does a change become a new habit? The rule of thumb used to be it takes approximately three weeks. However, the results of a study at the University of London showed that the time to form a habit, such as exercising, ranged from 18 days to 254 days (European Journal of Social Psychology, 40: 998–1009). The good news is that, though there was a wide variance, the average time to reach this automaticity was 66 days, or about two months.

Lifestyle modification:  Choosing a diet

U.S. News and World Report released its second annual ranking of diets last week. The panel included 22 weight-loss and nutrition experts. Three of the diets highlighted include the DASH (Dietary Approaches to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. All three diets were ranked in the top five for heart health. The DASH diet was ranked the No. 1 overall diet, and the Mediterranean diet was ranked No. 3. Both the Ornish and the DASH diets ranked within the top three for diabetes.

What do these diets have in common? They focus on nutrient-dense foods. In fact, the lifestyle modifications that I recommend are based on a combination of these three diets and the evidence-based medicine that supports them.

For instance, in a randomized crossover trial, which means patients after a prescribed time can switch to the more effective group, showed that the DASH diet is not just for patients with high blood pressure. The DASH diet was more efficacious than the control diet in terms of diabetes (decreased hemoglobin A1C 1.7 percent and 0.2 percent, respectively), weight loss (5 kg/11 lbs. vs. 2 kg/4.4 lbs.), as well as in HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (Diabetes Care. 2011;34:55-57).

Interestingly, patients still lost weight, although caloric intake and the percentages of fats, protein and carbohydrates were the same between the DASH and control diets. However, the DASH diet used different sources of these macronutrients. The DASH diet also contained foods with higher amounts of fiber, calcium and potassium and lower sodium.
Therefore, diets high in nutrient-dense foods may be an effective way to lose weight while treating and preventing disease.

Hopefully, I have inspired you to achieve your New Year’s resolutions. And one more tip: Don’t trip over the present looking to the future. In other words, take it day by day, rather than obsessing on the larger picture. Health and weight loss can — and should — go together.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website and/or consult your personal physician.

Exit interview with former county executive summarizes gripes; targets respond

Former Suffolk County Executive Steve Levy. File photo

By Elana Glowatz & Rachel Shapiro

Former County Executive Steve Levy was under no illusions that he would make friends when he took Suffolk’s top office eight years ago.

He stood his ground in long-term battles with the Suffolk County Police Benevolent Association and the Legislature and he says that paid off. When the PBA took out anti-Levy ads after the county executive shuffled police officers around to cut costs, he took it all in stride.

“You’ve got to have the backbone to stand up to that and not wilt,” Levy said in an interview. “Over time you’ll be proven correct, as we were with the highway patrol change and as we were with civilianization.”

PBA second vice president Noel DiGerolamo fired back in a phone interview Tuesday that “the only thing that was proven over time is that Steve Levy was not a person to be trusted or believed, as proven by his departure from the government … and his ongoing legal troubles with the [district attorney].” DiGerolamo was referring to Levy’s return of $4 million in campaign funds as part of an agreement with District Attorney Tom Spota, under which the county executive also agreed not to seek a third term.

Levy, 52, has declined on several occasions to discuss the details of the deal.

Other battles aside, Levy considers county Comptroller Joe Sawicki and Newsday’s editors and reporters to have played a part in trying to tarnish his reputation. In reflecting on his time as county executive, he painted a picture of the comptroller and the newspaper working to embarrass and discredit him.

Control battle with comptroller

One example he gave is Sawicki’s office performing an audit on the request for proposals process to sell the county-owned John J. Foley Skilled Nursing Facility, to determine whether the county had followed procedures correctly. Levy said he was interested in selling the nursing home to save the county money. When the report was completed, Levy said, the comptroller then “conveniently drops it on the table of the Legislature the same day they’re voting” on the sale, in order to sway the legislators to kill it.

But the comptroller told a different story. In an interview with Times Beacon Record Newspapers following Levy’s allegations, Sawicki said Presiding Officer Bill Lindsay (D-Holbrook) and legislators Kate Browning (WF-Shirley) and John Kennedy (R-Nesconset) requested the audit in November 2010, and his office was rushing to complete the report by March 2, 2011, the day of the vote. And according to Christina Capobianco, Sawicki’s chief deputy comptroller, the audit staff was “stonewalled” by the county Health Department and attorney’s office, delaying the process.

‘I think he became extremely paranoid over the years.’ — Joe Sawicki

However, Levy was not convinced. “It’s too cute to just so happen to finish your audit on the same day that the Legislature is voting on this issue,” he said. “If [Sawicki] was concerned about timing he simply could have mentioned this to the Legislature. He never did. … This was an 11th hour surprise to try to kill the deal.”

The Legislature ultimately voted to sell the nursing home, but the buyer, Kenneth Rozenberg, was no longer interested.

Levy said Sawicki had an agenda against him. He pointed to the fact that at the same time the nursing home audit was being performed, Sawicki donated money to the Nursing Home Support Fund for employees who were working to save the facility from closure, and he attended a fundraiser.

According to a New York State Board of Elections financial disclosure report, Sawicki donated $500 to that group on Jan. 10, 2011.

Levy called the act a conflict of interest and said that Sawicki was considering a run for county executive and was buying the support of the nursing home employees’ union. But the comptroller said although others had suggested it to him, he had not planned to run for county executive, and that his office’s audit and his support of keeping the nursing home open were “totally separate.”

Sawicki said his wife is a geriatric nurse at a private nursing home and that the Foley facility had a place in his heart.

“In my mind, helping the employees contribute to their legal fund to fight to stay open and keep their jobs is a lot different than an audit I was doing of the RFP process,” Sawicki said. “I would do it all over again.”

‘It’s too cute to just so happen to finish your audit on the same day that the Legislature is voting on this issue.’ — Steve Levy

In addition to Levy’s claim that Sawicki was trying to cast him in a negative light because of a potential run for county executive, Levy said there was friction because he would not approve some of the comptroller’s hires in order to save money.

Sawicki said Levy would block approval of employees hired within his department’s approved budget. Ultimately, various elected county officials called for legislation that would allow them to approve their own hires if they stayed within their budgets. The legislation passed.

Although Sawicki expressed frustration with the hiring situation, he said he never did anything to give Levy a bad name. “You can’t find anything that I did that exceeded my role as the comptroller,” Sawicki said. “I pride myself on being the chief fiscal watchdog. I like that title.”

The comptroller also said that Levy didn’t like being audited and “I think he became extremely paranoid over the years.”

Levy responded, “If I didn’t want him doing audits I would have been complaining from my first year in office.” He added, “It’s absolutely his role to do audits.”

Financial disclosure

The county executive also took issue with Newsday’s coverage of various subjects, including his financial disclosure forms and wife Colleen West-Levy’s business. In a series of articles beginning in 2010, Newsday investigated Levy’s filing of the state-mandated financial disclosure form.

Throughout some of Newsday’s stories, such as “Disclosure bill would force Levy to report to county,” published June 15, 2010, the reporter stated as a matter of fact that the county form was more thorough than the state form that Levy was filing. This statement was not attributed to any source. In at least one other story, the reporter has also cited unnamed officials for this information.

In the stories, the reporter interviewed political opponents of Levy, who are quoted as saying that the county executive was in violation of county law when he filed state forms instead of county forms.

Levy argued that the reporter left out crucial information, including three expert opinions, one from Mark Davies, that cited Levy’s requirement to file the state form and his compliance with county law.

Davies, former executive director of the Temporary State Commission on Local Government Ethics, has served on several ethics committees, including as co-chair of the Ethics Committee of the American Bar Association’s section of state and local government law. He is also an adviser to the American Law Institute’s Project on Public Integrity and an adjunct professor of law at Fordham Law School.

‘Newsday is proud of its reporters and editors who pursued this story thoroughly and fairly while withstanding repeated criticisms and even personal attacks.’ — Statement from Newsday

He said in a written testimony to the Suffolk County Legislature in September 2010, “Indeed a comparison of the state form and the Suffolk County form reveals that, on the whole, the state form is more extensive than the county form.” He gave examples of disclosure categories the county form does not include, such as offices in political parties and organizations; the nature of a filer’s business; agreements for future employment; assignments and transfers of income and interest to others for less than fair market value; securities held by a corporation for investment when the filer or his or her spouse owns or controls 50 percent or more of the corporation; gifts and reimbursements; and any information on the assets and liabilities of the filer’s dependent children.

The county form also does not ask the filer to list unpaid positions with entities that have no current business or licenses with the county, even if they had immediate past county business or have upcoming county business.

Davies argued that because the county form lacks these categories, it does not comply with state law. He recommended that the county adopt the state form, at least on an interim basis, until the county form is brought into compliance with state law.

In the past year, legislation has been introduced to bring the local form into compliance with New York State law.

Levy said he gave the reporter the information from Davies early on in the reporting to include in the story, but it was not printed.

In Newsday’s story “Levy defends financial disclosures,” published June 9, 2010, a chart compiled by the reporter highlights specific information that is required on the county form and not the state’s — but not vice versa. The chart correctly says the county form requires the filer list bank accounts, including the type of account, the nature of ownership and the name of the bank. The state form does not require this information.

With regard to real estate interests, both forms require disclosure of location, size, general nature, acquisition date, percentage of ownership and range of value of the property. The only difference between the forms is that the county’s requires the filer to name partners and the valuation date. The chart incorrectly states that the state form does not require market value. The form specifically asks for approximate market value.

The chart also incorrectly says that the state form does not ask the filer to list credit card debt. In fact, the filer must list liabilities, but the form provides many exceptions, credit card debt not being one of them. Tim Glynn, an attorney in Setauket concentrating in business law, said a credit card balance should be reported, according to the language of the form. However, if the balance was accrued by purchasing items that were exempted, the filer could leave the debt off the list.

Newsday’s chart correctly says the state form does not require disclosure of government contracts secured through competitive bidding or requests for proposals, while the county form does.

“What [the reporter] would gloss over and not put in is that I was required by law to file a state form instead of a county form,” Levy said. “Newsday tried to make it look like I was forum shopping for a particular form to file because I wanted to hide something. It’s total nonsense.”

Levy is required by state law to file the state form as a sitting member of the Pine Barrens Commission, a state agency. This fact was confirmed by the county Ethics Commission in a 2006 ruling. For his first two years in office, Levy filed both state and county forms. Following the ruling in 2006, he began filing only the state form. Similar to wording in other stories, Newsday describes the ruling in “Levy defends financial disclosures” by saying, “The county ethics commission — whose members were appointed or recommended by Levy — has allowed him to file a state disclosure form since 2006.” Levy argues that the language used makes it appear as if the commission is giving him special treatment when, in fact, it is upholding state law.

Despite this, in 2010 Levy filed county forms from the years he had missed — from 2006 to 2009. In an interview, Levy said he filed the county form for those years because he had nothing to hide.

Times Beacon Record Newspapers sat down with Newsday’s vice president of public affairs, Paul Fleishman, and presented Levy’s claims about Newsday. The paper declined to give responses to each allegation, and instead issued the following statement:

“The facts speak for themselves. Last year, following an investigation by the Suffolk County District Attorney’s office, then-Suffolk County Executive Steve Levy forfeited $4 million of campaign money and announced he would not run for re-election. Newsday is proud of its reporters and editors who pursued this story thoroughly and fairly while withstanding repeated criticisms and even personal attacks. Newsday has a long and respected history of straightforward and courageous investigative reporting on behalf of the people of Long Island, who depend on us to shed light on matters that are important to the public. It is a responsibility to our community that we take very seriously, approach thoughtfully and pursue with the utmost care, integrity and commitment to accuracy. We stand firmly behind our reporting and our coverage.”

Colleen West-Levy

As it probed Levy’s financial disclosure forms, Newsday also questioned the business practices of his wife, Colleen West-Levy. Specifically, Newsday listed companies that had worked with West-Levy’s firms and had also received county funds, seeking to determine if there was a connection between the two. West-Levy’s court reporting and transcription businesses, Enright and Enright Sten-Tel, had a relationship with various companies that contracted with the county, five of which were law firms that Newsday named in the July 8, 2010 article “A question of disclosure.” While the story said that three of those firms had a relationship with West-Levy’s companies before her husband took office, Levy said his wife had worked with all of them before he took office and the work was not the result of political connections.

Levy estimated that of his wife’s roughly 200 clients, only 10 to 15 of them had any connection to the county.

The article also named Stony Brook University Medical Center’s Cody Center and Good Samaritan Hospital, based in West Islip, in the investigation as to whether there could be a connection between the hospitals receiving county funds and West-Levy’s businesses working with the institutions.

A 2005 ruling from the Ethics Commission stated that West-Levy could continue her work with Stony Brook University Medical Center and with any other hospital in the county without posing a conflict of interest.

“To any objective reporter, that 2005 opinion from the county’s Ethics Commission should have ended any thought of this sensationalistic ‘gotcha’ story,” Levy said in a statement.

‘This inaccurate and irresponsible series of articles [goes] to great lengths to insinuate that Colleen built her businesses upon my becoming county executive.’ — Steve Levy

Levy takes issue with the nature of the stories about his wife. The lead of the July 8 story states, “Court reporting firms owned by Suffolk County Executive Steve Levy’s wife, Colleen West, have regularly received work from businesses that have been paid millions of dollars in county contracts in recent years.” In the 16th paragraph, on the second page of the story, Newsday cites Levy and his wife as saying she did not work on county business for the firms.

“This inaccurate and irresponsible series of articles [goes] to great lengths to insinuate that Colleen built her businesses upon my becoming county executive, and that she and I have somehow attempted to avoid proper disclosure,” Levy said in a July 2010 statement. In an interview, Levy called it “disgraceful reporting with numerous inaccuracies.”

In the case of a July 31 article, “Babylon lawyer to head group probing ethics commission,” Levy said it contains a “gross misrepresentation” of what is required to be listed on state financial disclosure forms. The state form requires the filer to list his or her sources of income and those of a spouse. However, the form says, “Do not list the name of individual clients, customers or patients.” The county form does not require the filer to list clients either.

In the July 31 article, the reporter writes, “Newsday reported earlier this month that court reporting firms owned by Levy’s wife, Colleen West, do business with at least seven county vendors that have received millions in payments from the county. Levy said he is not required to disclose his wife’s clients, even though the county form requires disclosing all sources of income, including those of a spouse.”

Levy takes issue with the story painting the picture that disclosing his wife’s clients and disclosing his wife’s income are one and the same. He also said, “Shockingly, Newsday failed to note that the county form likewise does not require or request a listing of individual clients,” and that this omission suggests that by filing the state form, he was attempting to hide information from the public.

In addition, in “A question of disclosure,” the Newsday reporter writes that in 2008 County Attorney Christine Malafi, at Levy’s request, wrote a letter to law firms receiving county business, making it clear that Enright was not on a list of court reporters that could be chosen for county business. Newsday said this was after the PBA raised questions about Enright doing county work. However, Levy said in an interview that it was in 2005, through Malafi, that he notified all county vendors that would use court reporting services that they were only to use the firm that was awarded the county bid, which was not Enright.

Concerned by the coverage, Levy said he presented Newsday several times with memos refuting information in various stories on several topics. Newsday did print a correction following an October 2010 story alleging Levy redacted personal financial information from his disclosure forms, when the Suffolk County Ethics Commission had actually redacted the information. But Levy said his concerns were largely limited to the letters page, instead of in further news reports or corrections.

In May 2011, the Press Club of Long Island announced Newsday’s main reporter on these stories won Outstanding Long Island Journalist. In 2009 the reporter, along with another Newsday reporter, won the Selden Ring Award for Investigative Reporting for a series of articles about special government districts.

The past, present and future

Levy said he made enemies because he “made tough decisions” — reorganizing the police department to save money, selling the Foley nursing home, limiting county hires and requiring union givebacks as a way to avoid county layoffs.

A fiscal conservative, Levy prided himself on saving money where he could. He said he gave up three bodyguards, took 240 county cars out of service, which had been “doled out like political lollipops.” He said his administration developed a different mind-set for county government, requiring double sign-offs for overtime and controlling travel expenditures. The county put its health care package out to competitive bid and saved $18 million annually, Levy said.

“Despite the tough times we’re having, we’re still in better shape than [surrounding counties] are and that’s because of the foundation that we’ve laid out over these many years. But it’s certainly not going to be easygoing into the next couple of years until the national economy picks up again.”

He doesn’t regret his run for governor, rather he said he would have been kicking himself if he hadn’t tried. He doesn’t regret his party change either, although he said it made him more of a target than when he was a Democrat. Levy said his switch to the Republican Party was not an act of political opportunism, having received endorsements of the Republican and Conservative parties; he won cross-party endorsements for his second term as county executive starting January 2008, winning 96 percent of the vote. The county executive had always leaned to the right economically and on the topic of immigration.

“It wasn’t a big leap, it wasn’t such a surprise to people in Suffolk,” Levy said.

But within one year of switching parties and announcing his run for governor, Levy made a deal with DA Spota to give back the $4 million in campaign funds and not seek re-election for a third term — ending his tenure under what many have called a cloud of suspicion.

Although he was forthcoming about other controversial issues, the county executive was tight-lipped about his agreement with Spota. He simply said, “We’ll have that conversation at another time.”

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Research shows TIA increases the risk of a heart attack by 200 percent

I recently helped manage a patient who had been diagnosed with a TIA: transient ischemic attack. The patient’s only symptom was double vision. A TIA is sometimes referred to as a ministroke. This is a disservice, since it makes a TIA sound like it should be taken lightly.

Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot that needs to be taken very seriously. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (Stroke. Apr 2005;36(4):720-3; Neurology. May 13 2003;60(9):1429-34). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. TIA incidence increases with age (Stroke. Apr 2005;36(4):720-3).

What is a TIA? The definition has changed from one purely based on time (less than 24 hours) to differentiate it from a stroke, to one that is tissue based. It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia — low blood flow in the back of the eye — without evidence of acute infarction (tissue death) (N Engl J Med. Nov 21 2002;347(21):1713-6).

It has been shown that tissue death and/or lesions can occur on diffusion-weighted MRI. In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, with difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Why take a TIA seriously if its debilitating effects may be temporary? TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death.


After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (Neurology 2011 Sep 27; 77:1222). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (Lancet Neurol. Dec 2007;6(12):1063-72).

Even worse, the probability that a patient will experience a stroke reaches approximately 30 percent after five years (Albers et al., 1999).

Heart attack

In a recent epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (Stroke. 2011; 42: 935-940). These are patients without known heart disease.

Interestingly, the risk of heart attacks was much higher in those under 60 years of age, and continued for years after the event. Just because you may have not had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack. Even patients taking statins to lower cholesterol were at higher risk of heart attack after a TIA.


TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years, and by 20 percent after nine years, especially in those over age 65, according to a study published in Stroke online, Nov. 10.

The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.


In a cohort (particular group of patients) study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (Stroke. 2011 Jul;42(7):1857-61). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (JAMA. 2005 Mar 23;293(12):1435). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include the Mediterranean and DASH diet combination I elaborated on in my Dec. 22 article, “Stroke prevention is the best treatment.” Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

In researching this article, I realized that there are not many separate studies for TIA since they are usually clumped with stroke studies. This underscores its seriousness. If you or someone you know has a TIA, the patient needs to see a neurologist and a primary care physician and/or cardiologist immediately.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website and/or consult your personal physician.

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Intensive medical counseling effective; reimbursement now approved by Medicare

Over the last week, I have been stunned by the incredible number of ads for New Year’s resolution diets, including ones specifically targeting men. I would like to talk about what may and may not work when dealing with weight loss. Obesity has dramatically increased over the last 30 years and now has reached epidemic proportions according to the Centers for Disease Control. By the year 2030, half of the U.S. population is expected to be obese (The Lancet 2011;378:741-748).

Obesity is associated with many chronic diseases, including heart disease, stroke, cancer, diabetes and osteoarthritis and is a major contributor to death (Ann Intern Med 2003;139:933-949).

So, why not start the new year with a positive step in the right direction? One of the top New Year’s resolutions is to lose weight. We need to act on this, and Medicare has recently provided an incentive for both patients and physicians. What do I mean by this? Medicare has approved reimbursement for intensive management of obesity by primary care physicians.

What does this include, and what is meant by intensive? Patients who are deemed obese, defined as a BMI (body mass index) >30kg/m2 are eligible for a year’s worth of intensive obesity counseling. This breaks down as follows: weekly visits to the physician for the first month and then every other week for months two through six. If the patient has lost a modest 6.6 pounds, then counseling can continue on a monthly basis for months seven through 12. This is a substantial step forward in the battle of the bulge. I commend the current administration for its efforts.

What have studies shown?
In a recent randomized clinical trial — the gold standard of trial designs — called the Practice-based Opportunities for Weight Reduction study, those who underwent more intensive weight-loss counseling through primary care physicians’ offices saw significant reduction in weight that was, most importantly, maintained over a two-year period (N Engl J Med 2011; 365:1959-1968). The mean change in weight was a loss of 5.1 kg, or 11.2 pounds, in the intensive group compared to the control group (usual care) who lost 0.8 kg, or 1.8 pounds. These results were statistically significant.

In a meta-analysis ( a group of studies), there was a 6.6 pound greater weight loss in the intervention group than the control group over 12 to 18 months with a greater number of treatment sessions resulting in a greater amount of weight loss (Ann Intern Med 2011;155:434-437).

There have been a number of other studies showing substantial weight loss over two years with a high nutrient density diet; participants shed a mean of 53 pounds over that period (Altern Ther Health Med. 2008 May-Jun;14(3):48-53), but it was not a randomized control trial.

The U.S. Preventive Services Task Force has been recommending obesity counseling for patients. It found that it helped to improved blood pressure, cholesterol levels and glucose metabolism, among other things, with even modest weight loss.

Calorie restriction approach: the problem
There are many programs doctors can choose from to help patients. However not all programs are equal. Severe calorie restriction may work for the short term, but is not really a solution for the long term. Complications arise when hormones, such as leptin, ghrelin, peptide YY, glucose-like peptide 1 (GLP-1) and insulin, are thrown out of balance and the body strives to replace the weight that has been lost (N Engl J Med 2011; 365:1597-1604). The hormones, instead of suppressing appetite, actually create an environment ripe for regaining weight, setting up the patient for failure. I touched on the physiologic effects related to weight loss in an article on Oct. 21, 2010.

The importance of nutrient dense foods
It is not as much about calorie restriction as it is about nutrients from foods. Nutrient dense substances not only help with weight loss, but are very important for treatment and prevention of disease. Regardless of whether someone is obese or not, nutrient-dense diets, such as the Mediterranean-type diet and the DASH diet, have shown tremendous benefit in the treatment and prevention of chronic disease. There is even a potential association between micronutrient (nutrient dense) food deficiencies and obesity (Nutr Rev. 2009 Oct;67(10):559-72). Thus, it is about lifestyle modification rather than “dieting.”

This is just too great an opportunity not to be a participating patient. Intensive guidance by the medical community can help patients lose weight, if done right, for the long term. The prevailing thought in medicine is that private insurance companies will follow suit, which would be great news for those not eligible for Medicare.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website and/or consult your personal physician.