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David Dunaief

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Walking is an easy way to help you lose weight, which will help relieve pain and restore function in your joints. Stock photo
Walking can reduce the risk of functional decline

By David Dunaief, M.D.

Dr. David Dunaief

As the population ages, we see more and more osteoarthritis (OA); and as the population gets heavier, we see more; and as people become more active, we see more; and as the population becomes more sedentary (weakened muscles), we see more. The point is that age, although a strong factor, may not be the only one.

Over 27 million people in the U.S. suffer from OA (1). Osteoarthritis is insidious, developing over a long period of time, and it is chronic by nature. It is a top cause of disability (2). What can we do about it?

It turns out that OA is not just caused by friction or age-related mechanical breakdown but rather by a multitude of factors. These include friction, but also local inflammation, genes and metabolic processes at the cellular level (3). Being a more complicated process means that we may be able to prevent and treat it better than we thought by using exercise, diet, medication, injections and possibly even supplements. Let’s look at some of the research.

How can exercise be beneficial?

In an older study, results showed that even a small 10-pound weight loss could result in an impressive 50 percent reduction of symptomatic knee OA over a 10-year period (4).

One of the exercises that most of us either can tolerate or actually enjoy is walking. We have heard that walking can be dangerous for exacerbating OA symptoms; the pounding can be harsh on our joints, especially our knees. Well, maybe not. Walking may have benefits. And once we figure out what exercise might be useful, in this case walking, how much should we do? In the Multicenter Osteoarthritis Study (MOST), results showed that walking may indeed be useful to prevent functional decline (5). But certainly not in overweight or obese patients and not older patients, right?

Actually, the patients in this study were a mean age of 67 and were obese, with a mean body mass index (BMI) of 31 kg/m2, and either had or were at risk of knee arthritis. In fact, the most interesting part of this study was that the researchers quantified the amount of walking needed to see a positive effect. The least amount of walking to see a benefit was between 3,250 and 3,750 steps per day, measured by an ankle pedometer. The best results were seen in those walking >6,000 steps per day, a relatively modest amount. This was random, unstructured exercise. In addition, for every 1,000 extra steps per day, there was a 16 to 18 percent reduced risk of functional decline two years later.

Walking is an easy way to help you lose weight, which will help relieve pain and restore function in your joints.

Where does vitamin D fit in?

For the last decade or so, we thought vitamin D was the potential elixir for chronic diseases. If it were low, that meant higher risk for disease, and we needed to replete the levels.

Well, a randomized controlled trial (RCT), the gold standard of studies, has shown that low vitamin D levels may indeed contribute to knee osteoarthritis (6). However, repleting levels of vitamin D did not seem to stem disease progression. In fact, it had no effect on the disease, to the bewilderment of the researchers. There was no change in joint space, knee pain, mobility or cartilage loss slowing. Hmm. The patients were supplemented with vitamin D 2,000 IU for two years.

There were 146 patients involved in the study. Blood levels of vitamin D were raised by 16.1 ng/ml in the treatment group to >36 ng/ml, which was significantly greater than the 2.1 ng/ml increase in the placebo group. Since the reasons for the results are unclear, work to maintain normal levels of vitamin D to possibly prevent OA, rather than wait to treat it later.

Acetaminophen may not live up to its popularity

Acetaminophen (e.g., Tylenol) is a popular initial go-to drug for the treatment of osteoarthritis, but what does the research say about its effectiveness? The answer might surprise you. Although acetaminophen doesn’t have anti-inflammatory properties, it does have analgesic properties. However, in a meta-analysis (involving 137 studies), acetaminophen did not reduce the pain for OA patients (7).

In this study, all other oral treatments were significantly better than acetaminophen including diclofenac, naproxen and ibuprofen as well as intra-articular (in the joint) injectables, such as hyaluronic acid and corticosteroids, except for an oral Cox-2 inhibitor, celecoxib, which was only marginally better.

What about NSAIDs?

NSAIDs (nonsteroidal anti-inflammatory drugs) by definition help to reduce inflammation. However, they have side effects that may include gastrointestinal bleed, and they have a black box warning for heart attacks. Risk tends to escalate with a rise in dose. But there is a twist: the FDA has approved a newer formulation of an NSAID, diclofenac (Zorvolex) (8). This formulation uses submicron particles, which are roughly 20 times smaller than the older version; since they provide a greater surface area, which helps the drug to dissolve faster, they require less dosage.

The approved dosage for OA treatment is 35 mg, three times a day. In a 602-patient, one-year duration, open-label randomized controlled trial, the newer formulation of diclofenac demonstrated improvement in pain, functionality and quality of life (9). The adverse effects, or side effects, were similar to the placebo. The only caveat is that there was a high dropout rate in the treatment group; only 40 percent completed the trial when they were dosed three times daily.

Don’t forget about glucosamine and chondroitin

Study results for this supplement combination or its individual components for the treatment of OA have been mixed. In a double-blind RCT, the combination supplement improved joint space, narrowing and reducing the pain of knee OA over two years. However, pain was reduced no more than was seen in the placebo group (10). In a Cochrane meta-analysis review study (involving 43 RCTs) results showed that chondroitin, with or without glucosamine, reduced the symptom of pain modestly compared to placebo in short-term studies (11). However, the researchers stipulate that most of the studies were of low quality.

So, think twice before reaching for the Tylenol. If you are having symptomatic OA pain, NSAIDs such as diclofenac may be a better choice, especially with SoluMatrix fine-particle technology that uses a lower dose and thus means fewer side effects, hopefully. Even though results are mixed, there is no significant downside to giving glucosamine-chondroitin supplements a chance.

However, if it does not work after 12 weeks, it is unlikely to have a significant effect. Also, try increasing your walking step count gradually; this could improve your risk of functional decline. And above all else, if you need to lose weight and do, you will reduce your risk of OA significantly.

References: (1) Arthritis Rheum. 2008;58:26-35. (2) Popul Health Metr. 2006;4:11. (3) Lancet. 1997;350(9076):503. (4) Ann Intern Med.1992;116:535-539. (5) Arthritis Care Res (Hoboken). 2014;66(9):1328-1336. (6) JAMA. 2013;309:155-162. (7) Ann Intern Med. 2015;162:46-54. (8) FDA.gov. (9) ACR 2014 Annual Meeting: Abstract 249. (10) Ann Rheum Dis. Online Jan 6, 2014. (11) Cochrane Database Syst Rev. 2015 Jan 28;1:CD005614.

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, visit www.medicalcompassmd.com or consult your personal physician.

The American Academy of Dermatology recommends sunscreen lotion with an SPF of 30 to be used daily by those who spend a lot of time in the sun.
Choose sunscreen and clothing as part of your sun protection regimen
Dr. David Dunaief

This holiday weekend, many headed to the beaches or fired up the outside barbecue for the first weekend of what’s shaping up to be a steamy summer. Long summer days spent outside conjure up pleasant images of friends and family relaxing together.

What could possibly be wrong with this picture? With all these benefits, you need to be cognizant of cutaneous (skin) melanoma. It is small in frequency, compared to basal cell and squamous cell carcinomas, responsible for only about 1 percent of skin cancers; however, it is much more deadly.

Statistics

Unfortunately, melanoma is on the rise. Over the last 40 years from 1970 to 2009, its incidence has increased by 800 percent in young women and by 400 percent in young men (1). These were patients diagnosed for the first time between 18 and 39 years old. Overall, the risk is greater in men, with 1 in 28 lifetime risk. The rate among women is 1 in 44. It is predicted that in 2017, there will have been over 87,000 new diagnoses, with over 11 percent resulting in death (2).

Melanoma risk involves genetic and environmental factors. These include sun exposure that is intense but intermittent, tanning beds, UVA radiation used for the treatment of psoriasis, the number of nevi (moles), Parkinson’s disease, prostate cancer, family history and personal history. Many of these risk factors are modifiable (3).

Presentation

Fortunately, melanoma is mostly preventable. What should you look for to detect melanoma at its earliest stages? In medicine, we use the mnemonic “ABCDE” to recall key factors to look for when examining moles. This stands for asymmetric borders (change in shape); border irregularities; color change; diameter increase (size change); and evolution or enlargement of diameter, color or symptoms, such as inflammation, bleeding and crustiness (4). Asymmetry, color and diameter are most important, according to guidelines developed in England (5).

It is important to look over your skin completely, not just partially, and have a dermatologist screen for potential melanoma. Screening skin for melanomas has shown a six-times greater chance of detecting them. Skin areas exposed to the sun have the highest probability of developing the disease. Men are more likely to have melanoma tumors on the back, while women are more likely to have melanoma on the lower legs, but they can develop anywhere (6).

In addition, most important to the physician, especially the dermatologist, is the thickness of melanoma. This may determine its probability to metastasize. In a retrospective (backward-looking) study, the results suggest that melanoma of >0.75 mm needs to not only be excised, or removed, but also have the sentinel lymph node (the closest node) biopsied to determine risk of metastases (7).

A positive sentinel node biopsy occurred in 6.23 percent of those with thickness >0.75 mm, which was significantly greater than in those with thinner melanomas. When the sentinel node biopsy is positive, there is a greater than twofold increase in the risk of metastases. On the plus side, having a negative sentinel node helps relieve the stress and anxiety that the melanoma tumor has spread. The two most valuable types of prevention are clothing and sunscreen. Let’s look at these in detail.

Clothing

Clothing can play a key role in reducing melanoma risk. The rating system for clothing protection is the ultraviolet protection factor (UPF). The Skin Cancer Foundation provides a list of which laundry additives, clothing and cosmetics that protect against the sun (8). Clothing that has a UPF rating between 15 and 24 is considered good, 25 and 39 is very good, and 40 and 50 is excellent. The ratings assess tightness of weave, color (the darker the better), type of yarn, finishing, response to moisture, stretch and condition. The most important of these is the weave tightness (9). There are many companies that produce fashionable and lightweight sun protective clothing lines. Gone are the days of needing to wear your jeans into the water while swimming to protect you from the sun.

Sunscreen

We have always known that sunscreen is valuable. But just how effective is it? In an Australian prospective (forward-looking) study, those who were instructed to use sun protective factor (SPF) 16 sunscreen lotion on a daily basis had significantly fewer incidences of melanoma compared to the control group members, who used their own sunscreen and were allowed to apply it at their discretion (10). The number of melanomas in the treatment group was half that of the control group’s over a 10-year period. But even more significant was a 73 percent reduction in the risk of advanced-stage melanoma in the treatment group. Daily application of sunscreen was critical.

The recommendation after this study and others like it is that an SPF of 15 should be used daily by those who are consistently exposed to the sun and/or are at high risk for melanoma according to the American Academy of Dermatology (11). The amount used per application should be about one ounce. However, since people don’t use as much sunscreen as they should, the academy recommends an SPF of 30 or higher.

Note that SPF 30 is not double the protection of SPF 15. The UVB protection of SPFs 15, 30 and 50 are 93, 97 and 98 percent, respectively. The problem is that SPF is a number that registers mostly the blocking of UVB but not so much the blocking of UVA1 or UVA2 rays. However, 95 percent of the sun’s rays that reach sea level are UVA. So what to do?

Sunscreens come in a variety of UV filters, which are either organic filters (chemical sunscreens) or inorganic filters (physical sunscreens). The FDA now requires broad-spectrum sunscreens pass a test showing they block both UVB and UVA radiation. Broad-spectrum sunscreens must be at least SPF 15 to decrease the risk of skin cancer and prevent premature skin aging caused by the sun. Anything over the level of SPF 50 should be referred to as 50+ (3).

The FDA also has done away with the term “waterproof.” Instead, sunscreens can be either water resistant or very water resistant, if they provide 40 and 80 minutes of protection, respectively. This means you should reapply sunscreen if you are out in the sun for more than 80 minutes, even with the most protective sunscreen (3). Look for sunscreens that have zinc oxide, avobenzone or titanium oxide; these are the only ones that provide UVA1 protection, in addition to UVA2 and UVB protection.

In conclusion, to reduce the risk of melanoma, proper clothing with tight weaving and/or sunscreen should be used. The best sunscreens are broad spectrum, as defined by the FDA, and should contain zinc oxide, avobenzone or titanium oxide to make sure the formulation not only blocks UVA2 but also UVA1 rays. It is best to reapply sunscreen every 40 to 80 minutes, depending on its rating. We can reduce the risk of melanoma occurrence significantly with these very simple steps.

References: (1) Mayo Clin Proc. 2012; 87(4): 328–334. (2) cancer.org. (3) uptodate.com. (4) JAMA. 2004;292(22):2771. (5) Br J Dermatol. 1994;130(1):48. (6) Langley, RG et al. Clinical characteristics. In: Cutaneous melanoma, Quality Medical, St. Louis, 1998, p. 81. (7) J Clin Oncol. 201;31(35):4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23(6):264. (10) J Clin Oncol. 2011;29(3):257. (11) aad.org.

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, visit www.medicalcompassmd.com or consult your personal physician.

Exercise may be a step toward reversing the metabolic clock.
Obscenely short intervals of exercise can still generate significant benefit
Dr. David Dunaief

By David Dunaief, M.D.

What better way to start an article than with a pretest?

1) What minimum amount of exercise will reduce cardiovascular disease risk?

a. 5 to 10 minutes per day b. 30 minutes most days c. 60 minutes most days d. I don’t care — I don’t like pretests

2) How does inactivity affect menopausal symptoms?

a. Increases hot flashes b. Worsens risk of anxiety and depressive moods c. Decreases memory and concentration d. B and C

3) Exercise may have an impact on the following: a. Changing gene expression b. Metabolic aging c. Weight management d. All of the above

With all that’s been written about exercise in the past few years, I’ll bet you did well. The answers to the quiz are: 1) a, 2) d, 3) d. Before we go further, let’s differentiate between physical activity and exercise. Physical activity involves skeletal muscle contraction. It’s an umbrella term that includes exercise, but it also includes housework, yard work, movement on the job, etc. Exercise involves repetitive movements, structure and goal orientation such as walking, running, resistance training or playing sports (1). While you want to be physically active, exercise has more benefit.

We have long-held paradigms in medicine that may or may not be accurate. Medicine is always changing with the evolution of evidence-based research. We know that exercise has benefits for helping to prevent and possibly reverse some chronic diseases, but it also may have benefit for menopausal symptoms, slowing the metabolic aging process and even changing our genes, or at least gene expression.

The Fountain of Youth

Ponce de León sought a physical fountain of youth. While we tend to chuckle at that thought, metaphorically there may be at least some truth to the mythical fountain. Exercise may be a step toward reversing the metabolic clock. Until recently, we thought that when we hit 40 years old, we should expect a decline in physical abilities, with each passing year raising the probability of greater muscle atrophy. This may not actually be the case. Just because a paradigm has been around a long time does not make it correct.

In a small observational study, results showed that the participants, spanning ages 55 to 79, were unable to be differentiated based on age for the majority of tests (2). In other words, those who were in their 70s performed similarly to those in their 50s for many, but not all, parameters. It would be impossible to tell who was what age based purely on the data.

Participants were also compared to standards related to typical aging in each group, such as comparing 70-year-old cyclists versus inactive 70-year-olds. The ones who were cyclists were metabolically much younger. Thus, the researchers concluded that activity, rather than chronological age, may play a more important role in the aging process. The cyclists were not professional athletes, though they were required to pass a cycling endurance test prior to being accepted into the study. To at least some degree, we are more in control of our aging than we had thought. This is good news; we would all like to turn back the physical clock.

Can we really change our genes?

One of the greatest achievements of modern medicine has been mapping the human genome. However, gene therapy mostly has lagged. Well, there is a field called epigenetics. This word literally means “above” or “on” the gene. Epigenetics explores how to alter which of our genes get expressed and how. How can we do this? Methyl groups, one of the most basic groups of atoms in organic chemistry, latch on to genes and help to turn on and off their expression. Lifestyle modifications, like exercise, influence methylation groups to affect genes.

In a small study, results showed greater than 5,000 alterations in the genes of muscle cells such that there were different patterns of methyl groups that occurred in exercised legs compared to inactive legs (3). The genes that were affected are known to be involved in insulin sensitivity and inflammation. Let me explain further.

The researchers had 23 healthy volunteers use a stationary bike for 40 minutes, four times a day, for three months. Here is the catch: Participants only used one leg and did not exercise the other leg, limiting confounding variables. In the same participant, the leg that was exercised had dramatic changes in gene expression, whereas the other leg did not.

How can exercise elongate cell life?

In another study, exercise appeared to prevent or reduce the risk of shortened telomeres. Telomeres are important for protecting the DNA and, ultimately, the cell (4). There were four different categories of exercises surveyed. If respondents said yes to each category, there was an exponentially greater chance that they would not have very short telomeres.

The categories included walking, running, walking/riding a bike to work or school and weight lifting. When a participant was involved in one category in the previous month, there was a 3 percent reduced risk of shorter telomeres, whereas participants who were involved in all four categories had a 59 percent reduced risk of having very short telomeres. This greatest impact was seen in adults between ages 40 and 65.

Menopause symptoms

Although menopause is a rite of passage for women, not a disorder, there are symptoms that may negatively impact quality of life. Exercise may help alleviate menopausal symptoms. In a study, women who exercised regularly (resistance training twice weekly, plus either 150 minutes weekly of moderate activity, like walking, or 75 minutes weekly of intense exercise, like jogging or running) had a better overall sense of well-being and fewer symptoms during menopause compared to their less active counterparts (5). Those who were less active were more likely to be in depressed/anxious moods, have “brain fog,” difficulties with memory and concentration and experience increased vasomotor symptoms. Interestingly though, there was no change in hot flashes between the two groups.

I don’t have time to exercise!

There have been several studies that have shown that you can have obscenely short intervals of exercise and still get significant benefit. In one study, a one-minute intensive interval was broken into 20-second intervals within 10 minutes of exercise three times a week (6). Overweight participants had improved blood pressure and endurance capacity, as well as beneficial gains among other parameters.

In another study, as little as five to 10 minutes of running a day reduced the risk of dying from any cause by 30 percent and dying from heart disease by 45 percent (7). The best part of the results was that there was a significant difference between runners and nonrunners, but not between those who ran at a less-than-six-minute-mile pace and those who ran at a slower-than-10-minute-mile pace.

References: (1) uptodate.com. (2) J Physiol. online Jan. 6, 2015. (3) Epigenetics. Dec. 7, 2014. (4) Med Sci Sports Exerc. 2015;47(11):2347-2352. (5) Maturitas. 2015 Jan;80(1):69-74. (6) PLoS One. 2014;9(11):e111489. (7) J Am Coll Cardiol. 2014;64(5):472-481.

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, visit www.medicalcompassmd.com or consult your personal physician.

Early treatment is crucial

By David Dunaief, M.D.

Dr. David Dunaief

Ah, summer is upon us. Unfortunately, this means that tick season is getting into full swing. Projections for this year’s tick population are ominous, because of seemingly unrelated issues like an increase in last year’s acorn population, which feeds mice that are carriers, and a relatively mild winter (1).

Thus, it is good timing to talk about Borrelia burgdorferi, better known as the bacteria that causes Lyme disease. This bacteria is from the spirochete class and is typically found in the deer tick, also known as the blacklegged tick.

What do deer ticks look like? They are small and can be as tiny as a pencil tip or the size of a period at the end of a sentence. The CDC.gov site is a great resource for tick images and other information related to Lyme disease.

What if you have been bitten by a tick? The first thing you should do is remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick, for doing so may spread infectious disease (2). In the study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The National Institutes of Health recommend not removing a tick with oil (3).

The deer tick on the right is about half the size of a dog tick,
as seen on the left.

When a tick is removed within 36 to 48 hours, the risk of infection is quite low, according to the Centers for Disease Control and Prevention (4). However, a patient can be given a prophylactic dose of the antibiotic doxycycline, one dose of 200 mg, if the erythema migrans, or bulls-eye rash — a red outer ring and red spot in the center — has not occurred, and it is within 72 hours of tick removal (5). Those who took doxycycline had significantly lower risk of developing the bulls-eye rash and thus Lyme disease; however, treatment with doxycycline did have higher incidence of nausea and vomiting than placebo.

What are the signs and symptoms of Lyme disease? There are three stages of Lyme disease: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late-stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue (54 percent), muscle pain and joint pain (44 percent), headache (42 percent), neck stiffness (35 percent), swollen glands (23 percent) and fever (16 percent) (6).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory radiculoneuropathy (nerve roots of spinal cord). Late disseminated disease can cause Lyme arthritis (inflammation in the joints), heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (3).

How do we prevent this disease? According to the CDC, we should wear protective clothing, spray ourselves with insect repellent that includes at least 20 percent DEET and treat our yards (4). Always check your skin and hair for ticks after walking through a woody or tall grassy area. Many of us on Long Island have ticks in the yard, so remember to check your pets; even if treated, they can carry ticks into the house. My Golden Retriever, Buddy, whom I loved dearly, died of Lyme complications.

Diagnosis of Lyme disease

Many times Lyme disease can be diagnosed within the clinical setting. When it comes to serologic or blood tests, the CDC recommends an ELISA test followed by a confirmatory Western blot test (4). However, testing immediately after being bitten by a tick is not useful, since the test will tend to be negative, regardless of infection or not (7). It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (8). These antibodies sometimes remain elevated even after successful treatment with antibiotics.

The cardiac impact

What are some of the complications of Lyme disease? Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death due to second- or third-degree atrioventricular (AV) node conduction (electrical) block. Among the 1.1 percent who had Lyme carditis, there were five sudden deaths (9). If there are symptoms of chest pain, palpitations, light-headedness, shortness of breath or fainting, then clinicians should suspect Lyme carditis.

Does chronic Lyme disease exist?

There has been a debate about whether there is something called “chronic Lyme” disease. The research, unfortunately, has not shown consistent results that indicate that it exists. In the most recent report, chronic Lyme is refuted (10). In the analysis, the authors comment that the definition of chronic Lyme disease is obfuscated and that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes, according to several prospective trials. The authors do admit that there are prolonged neurologic symptoms in a subset population that may be debilitating even after the treatment of Lyme disease. These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment.

A previous analysis suggested that chronic Lyme may indeed exist and that post-Lyme disease syndrome is a nebulous term (11). The authors point to several randomized controlled trials (RCT) to help validate their point (12). They believe that the bacteria may be able to evade shorter courses of antibiotics.

Ultimately, it comes down to the IDSA (Infectious Diseases Society of America) arguing against chronic Lyme but in favor of post-Lyme disease syndromes, while the ILADS (International Lyme and Associated Diseases Society) believes chronic Lyme exists.

Regardless, the lingering effects of Lyme can be debilitating. This may be as a result of systemic inflammation (13). Systemic inflammation and its symptoms can be improved significantly with dietary and other lifestyle modifications.

But to throw one more wrench in the mix, the CDC recommends that physicians look beyond Lyme for other possible diagnoses before diagnosing someone with chronic Lyme disease (14).

So what have we learned? Prevention is key to helping stem Lyme disease. If this is not possible, treating prophylactically when pulling off a tick is an important step. Contact your physician as soon as you notice a tick. If you have a bulls-eye rash and it is early, then treatment for two to three weeks needs to be started right away. If it is prolonged and disseminated, then treatment should be for approximately three to four weeks with antibiotics. If it has affected the central nervous system, then IV antibiotics could be needed. Post-Lyme syndrome vs. chronic Lyme disease needs to be discussed with your physician. Symptoms attributed to chronic Lyme could have another cause.

References: (1) npr.org online March 6, 2017. (2) Pediatrics. 1985;75(6):997. (3) nlm.nih.gov. (4) cdc.gov. (5) N Engl J Med. 2001;345(2):79. (6) N Engl J Med. 2003;348(24):2472. (7) Clin Infect Dis. 2008;47(2):188. (8) uptodate.com. (9) MMWR. 2014;63(43):982-983. (10) Expert Rev Anti Infect Ther. 2011;9(7):787-797. (11) Future Microbiol. 2008;3(6):621-624. (12) Neurology 70,992-1003 (2008). (13) J Infect Dis. 2009;199(9:1379-1388). (14) JAMA Intern Med. online Nov. 3, 2014.

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, visit www.medicalcompassmd.com or consult your personal physician.

Studies show that wine may have heart benefits in well-controlled patients with type 2 diabetes.
Wine — yes, wine — may have benefits

By David Dunaief, M.D.

Dr. David Dunaif

Soda has a lot of sugar, with 39 grams per 12-ounce can. Not surprisingly, soda is associated with increased risk of diabetes. However, the drink with the lowest amount of sugar is wine, red or white. Even more surprising, it may have benefits in reducing complications associated with diabetes. Wine has about 1.2 grams of sugar in five ounces. I know what you’re thinking: These different drinks are based on different quantities; however, per ounce, soda has the most and wine has the least.

Why is this important? Well, it wouldn’t be if diabetes were going the way of the dodo bird. Instead, the prevalence of diabetes has continued to climb over three decades in the United States at an alarmingly rapid rate to its current level of 12 to 14 percent (1). The even scarier news is that more than one-third don’t know they have diabetes. The number of patients with prediabetes (HbA1C of 5.7-6.4 percent) is greater than one in three in this country.

So where do we stand? Only recently did the United States Preventive Services Task Force (USPSTF) and the American Diabetes Association (ADA) converge on screening guidelines. However, originally, the USPSTF recommended that asymptomatic patients not be screened for diabetes since the evidence is inconclusive and screening may not improve mortality. Now they give the evidence a grade of B, which means there is a moderate amount of evidence, not even a grade of A. ADA guidelines suggest testing those who are overweight and who have one or more risk factors for diabetes and all of those who are over 45 (2, 3).

It turns out that, for those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women had greater risk than men. In one study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (4). This was a retrospective (backward-looking) study. The same result was found in a second study (5). In this meta-analysis (a group of 19 studies), there was a 38 percent greater increased risk of cardiovascular events in women than men. The latter was presented as a poster, not fully published data.

What may reduce risks of disease and/or complications? Fortunately, we are not without options. Several factors may help. These include timing of blood pressure medications, lifestyle modifications (diet and exercise) and wine.

Diet trumps popular drug for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (7). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. While these are impressive results that speak to the use of lifestyle modification and to metformin, this is not the optimal diabetes diet.

Wine is beneficial, really?

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (6).

Patients were randomized into three groups, each receiving a drink with dinner nightly; one group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed on how to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Drugs — not diabetes drugs — show good results

In the May 11, 2017 column I wrote that taking blood pressure medications at night may control blood pressure better than only taking these medications in the morning. Well, it turns out this study also shows that taking blood pressure medications has another benefit, lowering the risk of diabetes (8). There was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a nonideal diet, in comparison to medication, had better results, though medication such as metformin could be used in high-risk patients that were having trouble following the diet. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References: (1) JAMA 2015;314(10):1021-1029. (2) uspreventiveservicestaskforce.org. (3) Diabetes Care 2015;38(Suppl. 1): S1–S94. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (5) EASD 2015; Poster #269. (6) Ann Intern Med. 2015;163(8):569-579. (7) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (8) Diabetologia. Online Sept. 23, 2015.

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, visit www.medicalcompassmd.com or consult your personal physician.

Treatment options vary wildly

By David Dunaief, M.D.

Dr. David Dunaief

With summer almost here and — believe it or not — beach weather around the corner, millions of Americans will expose their toes. Some will be more self-conscious about it than others because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many patients are bothered by this disorder. Most patients consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat and can be quite uncomfortable. Onychomycosis affects approximately 8 percent of the population (2). The risk factors are unclear but may be relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected by it (3).

There are many organisms that can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A test commonly used to differentiate the organisms is a KOH (potassium hydroxide) preparation, which is a simple microscopic exam of skin and nail shavings. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of the autoimmune disease psoriasis.

There are a plethora of therapies available for treatment. These range from over-the-counter alternative therapies to prescription topical medications to systemic, or oral, prescription therapies to laser therapies and, finally, surgery. I am regularly asked which treatment works best.

With all of these options, how is one to choose? Well, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. So there is no overnight success. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Fortunately, most cases of nail fungus are benign, with only a fraction leading to infections. Infection is most common in those with diabetic neuropathy, where the patient loses feeling in their feet. Let’s look at the evidence.

Oral antifungals

There are several options for oral antifungals, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These medications tend to have the greatest success rate, but the disadvantages are their side effects.

In a small but randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of the fungus in their toenails with terbinafine, whereas 21 and 32 percent experienced these benefits with fluconazole, depending on the duration. The patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with those in the 24-week group experiencing the better results.

Thus, this would imply that terbinafine is the more effective drug. This is a small trial, but the results are intriguing. The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine. Its advantages are the efficacy and the duration.

Another approach to reducing side effects is to give oral antifungals in a pulsed fashion. In a RCT, fluconazole 150 or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, the efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, the disadvantages are that it takes approximately a year of daily use, and its efficacy is not as great as the oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In one trial, ciclopirox had to be applied daily for 48 weeks. These results were in patients with mild to moderate levels of fungus in the surface area of the infected nails.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. To make matters worse, many laser treatments are not covered by insurance, and they can be expensive. Another research paper that reviewed the current literature concluded that laser therapies are lacking in randomized clinical trials (10).The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if they are effective.

Alternative therapy

The success of using this product is largely due to its ingredients, which includes menthol, camphor and eucalyptus oil.

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Additionally, partial improvement occurred in the toenails of 10 patients. But what is more interesting is that all 18 patients rated the results as either “satisfying” or “very satisfying.” The gel was applied daily for 48 weeks. The advantages are low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and a lower efficacy when compared to oral antifungals.

So when it comes to onychomycosis, what should one do? None of the treatments are perfect. Oral medications tend to be the most efficacious but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance.

If you decide on this approach, discuss it with your doctor; there are appropriate precautionary tests, such as liver enzyme monitoring with terbinafine (Lamisil), that need to be done on a regular basis. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better initial choice. No matter what you and your physician agree upon as the appropriate treatment, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References: (1) J Am Acad Dermatol. 1999 Aug.;41:189–196; Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Dermatol Online J. 2013 Sept. 14;19:19611. (11) J Am Board Fam Med. 2011;24:69–74.

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, visit www.medicalcompassmd.com or consult your personal physician.

A recent study showed that men who ate greater amounts of fish — more than one serving per week — had lower resting heart rates than those who ate fish rarely.
Resting heart rate is a predictor of disease

By David Dunaief, M.D.

Dr. David Dunaief

Everyone has a heart rate, so everyone needs to pay attention. But what does that heart rate, or pulse, tell us beyond the obvious fact that we are alive?

Our “normal” resting heart rate is between 60 to 100 beats per minute (bpm). We know that a resting heart rate (RHR) above 100 bpm is abnormal. It is referred to as tachycardia, or a racing heartbeat, and it has potentially serious consequences. However, even normal RHRs can be stratified to identify risks for diseases. What I mean is that, even in the normal range, as your resting heart rate increases, so do your potential risks. Actually, resting heart rate below approximately 70 bpm may be ideal.

The importance of the resting heart rate should not be underestimated. In fact, it may play a role in longevity, heart disease — including heart failure, arrhythmias, heart attacks and sudden cardiac death — and even chronic kidney disease. The good news is that RHR is modifiable. Methods that may reduce your rate include medications for high blood pressure, such as beta blockers, and lifestyle modifications, including meditation, dietary changes and exercise.

Impact on life span

We all want to live longer and healthier lives. Reducing the RHR may be an important component in achieving this goal. In the Copenhagen Male Study, a prospective (forward-looking) study that followed 2,798 participants for 16 years, results showed that those with higher resting heart rates had a greater risk of death (1). There was a linear relationship between the risk of death and increasing RHR. Those who had a resting heart rate above 90 bpm were at a threefold greater risk of death, compared to those who had a RHR at or below 50 bpm. RHR was inversely related to the amount of physical activity.

Thus, the authors concluded that a “healthy” person with higher RHR may still have a shorter life span, with all other factors being equal, such as physical activity and blood pressure.

In contrast with the previous study, the following one took a “glass is half-full” approach to longevity. The Jerusalem Longitudinal Cohort Study showed that elderly women and men who had a lower RHR lived the longest (2). There were more than 2,000 study participants, ranging from 70 to 90 years old.

Heart disease mortality

In the Nord-Trondelag Health Study, a prospective observational study, those who had a higher RHR at the end of the study than they did at the beginning of the study 10 years prior were more likely to die from heart disease (3). In other words, as the RHR increased from less than 70 bpm to over 85 bpm, there was a 90 percent greater risk of heart disease, compared to those who maintained a RHR of less than 70 throughout the two measurements. This study involved 30,000 participants. However, unlike some other studies, many of us can relate to the population: They were at least 20 years old and were healthy volunteers.

Heart attacks

It is more common for women to have heart attacks with atypical symptoms than men. Therefore, it is very important for women to reduce their heart attack risks. In the Women’s Health Initiative, results showed a 26 percent decrease in the risk of cardiovascular events in those postmenopausal women who had a RHR below 62 bpm, compared to those who had a RHR above 76 bpm (4). Interestingly, these results were even more substantial in the subgroup of women who were newly postmenopausal, ranging in age from 50 to 64.

 Effect on kidney function

I have written many times about chronic kidney disease. I thought an interesting follow-up might be resting heart rate and its impact on kidney function. In the Atherosclerosis Risk in Communities Study, results showed that the most severe form of chronic kidney disease, end-stage renal disease, was 98 percent more likely to occur in those with the highest RHR, compared to those with the lowest (5). There were approximately 13,000 participants in the study, with a 16-year follow-up. The authors hypothesized that this negative effect on the kidney may be due to a loss of homeostasis in the autonomic (involuntary) nervous system, resulting in blood vessel dysfunction, such as increased inflammation and vasoconstriction (narrowing).

Eating fish

What can be done to reduce the resting heart rate with minimal side effects? Fish consumption has recently been shown to have a positive effect. In a study, European men who ate greater amounts of fish — more than one serving per week — had lower resting heart rates than those who ate fish rarely (6). There was also a direct relationship between the amount of fish consumed and the RHR: the more fish consumed per week, the greater the reduction in RHR. This was a prospective observational study involving about 5,000 men. Some beneficial side effects of eating fish included decreased triglycerides and diastolic (lower number) blood pressure, as well as increased HDL (“good cholesterol”).

Even after controlling for these beneficial side effects, there still was a significant improvement in RHR with fish consumption. Is there a resting heart rate that is too low? Well, it depends on the context. If you are a marathoner or an athlete, then a RHR in the 40s may not be abnormal. For a healthy, physically active individual, it is not uncommon to have a resting heart rate in the 50s. However, if you are on medications that reduce your RHR and/or have a chronic disease, such as heart failure, it is probably not advisable to go much below 60 bpm. Always ask your doctor about the appropriate resting heart rate for your particular situation.

Thus, resting heart rate is an easy and inexpensive biomarker to potentially determine risk stratification for disease manifestation and to increase longevity, even for those in the normal range. We can utilize RHR as a tool for primary prevention of disease. The fact that it is modifiable means it is something that we need to monitor, so that we can achieve the ideal RHR, rather than just the normal.

References: (1) Heart Journal 2013 Jun;99(12):882-887. (2) J Am Geriatr Soc. 2013;61(1):40-45. (3) JAMA 2011; 306:2579-2587. (4) BMJ. 2009 Feb 3;338:b219. (5) J Am Soc Nephrol. 2010 Sept;21(9):1560-1570. (6) Circulation. 2003;108:820-825.

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, visit www.medicalcompassmd.com or consult your personal physician.

A recent study showed that patients who are very obese could lose almost two decades of healthy living
Quality of life impacts are considerable

By David Dunaief, M.D.,

Dr. David Dunaief

The media is increasingly focused on covering obesity-related issues. With this in mind, let’s start off with a short quiz to test your knowledge of obesity-related issues. The answers and research are provided below. Regardless of your quiz score, it is important to understand the research.

1. Obesity reduces life span by up to:

A) Not at all

B) 4 years

C) 8 years

D) 10 years

2. Obesity shortens healthy years of life by:

A) 8 years

B) 12 years

C) 15 years

D) 20 years

3. Food cravings can be reduced for the short term by:

A) Counting to 20

B) Tapping your finger against your head

C) Watching TV

D) Texting on your cellphone

4. Obesity can lead to the following complication(s):

A) High blood pressure

B) Diabetes

C) Cancer

D) All of the above

Are you eager to find out the answers? I hope so, because there are some very salient points I am trying to make by providing multiple choice questions. The answers are: 1. D; 2. D; 3. B; 4. D. So how did you do? One of the questions was actually similar to a question on a medical website for doctors, so don’t be too hard on yourself if you did not get them all right. Let’s look at the research.

Mortality and effect on life span

Many of you know that obesity could have an impact on development of other chronic diseases and a decrease in quality of life, but to what extent? A 2013 study indicated that almost as many as one in five deaths in the U.S. is associated with obesity (1).

In a computer modeling study, the results showed that those who are obese may lose up to eight years, almost a decade, of their life span (2). But that is only part of the results. The other, more compelling result is that patients who are very obese, defined as a BMI >35 kg/m², could lose almost two decades of healthy living. According to the researchers, this means you may have diseases such as diabetes and cardiovascular disease. However, even those patients who were obese and those who were overweight also could have reductions in life span, up to 6 years and 3 years, respectively.

There were 3,992 adults between the ages of 20 and 79 evaluated in this study. The data was taken from an NHANES database from 2003 to 2010, which looked at participants who went on to develop diabetes and cardiovascular disease. Though this is not a clinical trial, and there is a need for more study, the results are eye-opening, with the youngest and very obese negatively impacted the most.

Cancer impact

Since it is very difficult to “cure” cancer, although hopefully someday soon we will, it is important to reduce modifiable risk factors. Obesity may be one of these contributing factors, although it is hotly debatable how much of an impact obesity has on cancer development.  The American Society of Clinical Oncologists (ASCO), in a position paper, supported the idea that it is important to treat obesity in the fight against cancer (3). The authors indicate obesity may make the prognosis worse, may hinder the delivery of therapies to treat cancer, and may increase the risk of malignancy.

Also, possibly reinforcing ASCO’s stance, a study suggested that upward of a half-million cases of cancer worldwide were related to being overweight or obese, with the overwhelming concentration in North American and Europe (4).

Possible solutions

A potential counterweight to both the reductions in life quality and life expectancy may be the Mediterranean diet. In a published analysis of the Nurses’ Health Study, results show that the Mediterranean diet helped slow shortening of the telomeres (5). Repeat sequences of DNA found at the end of chromosomes, telomeres, shorten with age; the shorter the telomere, the shorter life expectancy.

Thus, the Mediterranean diet may decrease occurrence of chronic diseases, increase life span and decrease premature mortality — hence, the opposite effect of obesity. In fact, it may help treat obesity, though this was not mentioned in the study. Interestingly, the effects of the Mediterranean diet were on a dose-response curve. The greater the adherence to the diet, rated on a scale of 0 to 9, the better the effect. Those who had an increase in adherence by three points saw a corresponding decrease in telomere aging by 4.5 years. There were 4,676 middle-aged women involved in this analysis. The researchers believe that the anti-inflammatory and antioxidant effects could be responsible for the diet’s effects.

According to an accompanying editorial, no individual component of the diet was identified as having beneficial effects by itself, so it may be the diet as a whole that is important (6).

Short-term solutions

There are easy-to-use distraction tactics that involve physical and mental techniques to reduce food cravings. These include tapping your foot on the floor, staring at a blank wall and, yes, alternating tapping your index finger against your forehead and your ear (7). The forehead and ear tapping was most effective, although probably most embarrassing in public. Among mental techniques, seeing pictures of foods that were unhealthy and focusing on their long-term detriments to health had the most impact (8). All of these short-term distractors were done for 30 seconds at a time. The results showed that in obese patients they indeed decreased food cravings.

Exercise impact

I have written about exercise and that it does not lead to fat percentage loss in adults. Well, before you write off exercise for fat loss, it seems that adolescents may benefit from exercise. In a randomized controlled trial, the gold standard of studies, results show that those in the resistance training group alone and those in a combined resistance and aerobic training group had significantly greater percentages of fat loss compared to a control group (9).

However, the aerobic group alone did not show a significant change in fat percent versus the control. There were 304 study participants, ages 14 to 18, followed for a six-month duration, and results were measured with MRI. The reason that resistance training was effective in reducing fat percentage may have to do with an increase in muscle mass rather than a decrease in actual fat. Still, exercise is important. It doesn’t matter if it decreases the fat percentage; it is still getting you to the goal.

Obesity can have devastating effects, from potentially inducing cancer or worsening it, to shortening life expectancy and substantially decreasing quality of life. Fortunately, there may be ways to help treat obesity with specific lifestyle modifications. The Mediterranean diet as a whole may be an effective step toward decreasing the burden of obesity and reducing its complications. Kids, teenagers specifically, should be encouraged to “Play 60,” as the NFL has encouraged, but also to do some resistance training. As we mentioned, there are simple techniques that may help reduce short-term food cravings.

References: (1) Am J Public Health. 2013;103:1895-1901. (2) The Lancet Diabetes & Endocrinology, online Dec. 5, 2014. (3) J Clin Oncol. 2014;32(31):3568-3574. (4) The Lancet Oncology. online Nov. 26, 2014. (5) BMJ. online Dec. 2, 2014. (6) BMJ 2014;349:g6843. (7) Obesity Week 2014 abstract T-2658-P. (8) Obesity Week 2014 abstract T-3023-OR. (9) JAMA Pediatr. 2014;168(11):1006-1014.

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, visit www.medicalcompassmd.com or consult your personal physician.

Hypertension risk factors include poor diet, lack of exercise, age and depression.
Complications are highest during sleeping hours

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension (high blood pressure) deserves a substantial amount of attention. There are currently about 76 million people with high blood pressure in the U.S. Put another way, one in three adults have this disorder (1). If that isn’t scary enough, the Centers for Disease Control and Prevention reports that the number of people dying from complications of hypertension increased by 23 percent from 2000 to 2013 (2).

And talk about scary, it turns out that fear of the boogie man should take a back seat to high blood pressure during nighttime sleeping hours. This is when the probability of complications, such as cardiovascular events and mortality, may have their highest incidence.

Unfortunately, as adults, it does not matter what age or what sex you are; we are all at increased risk of complications from high blood pressure, even isolated systolic (top number) blood pressure, which means without having the diastolic (bottom number) elevated as well. Fortunately, hypertension is highly modifiable in terms of reducing the risk of cardiovascular disease and mortality (3). At least some of the risk factors are probably familiar to you. These include being significantly overweight and obese (BMI >27.5 kg/m²), smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol (4).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, there are nonpharmacological approaches that have benefits. These include lifestyle modifications with diet, exercise and potentially supplements. An item on the game show “Jeopardy” read: “You can treat it with diet and lifestyle changes as well as drugs: HBP.” The corresponding answer was, “What is high blood pressure?” We made the big time!

Risk factors matter, but not equally

In a study, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (5). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²) at 1.87 times increased risk. This surprisingly, albeit slightly, trumped cigarette smoking at 1.83 times increased risk. Interestingly, weekly binge drinking at 1.87 times increased risk was equivalent to being overweight. This study was observational and involved 2,763 participants. The moral is that a freewheeling lifestyle can have a detrimental impact on blood pressure and cause at least stage 1 hypertension (systolic between 140 and 159 mmHg and/or diastolic between 90 and 99 mmHg).

High blood pressure doesn’t discriminate

One of the most feared complications of hypertension is cardiovascular disease, because it can result in death. In a study, isolated systolic hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (6). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, which is not the best, it was very large and had a 31-year duration.

Nightmares that may be real

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), the results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (7).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration. Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (8). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

Previously, a study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (9). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Dietary tidbits

Diet plays a role in controlling high blood pressure. In a study, blueberry powder (22 grams) in a daily equivalent to one cup of fresh blueberries reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (10). This is not bad, especially since the patients were prehypertensive, not hypertensive, at baseline, with a mean systolic blood pressure of 138 mmHg.

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase a substance called nitric oxide, which helps blood vessels relax, reducing blood pressure.

The results of another study showed that girls who consumed higher levels of potassium-rich foods had a significant reduction in both systolic and diastolic blood pressure (11). The highest group consumed at least 2,400 mg of potassium daily, whereas the lowest group consumed less than 1,800 mg. The girls were 9 and 10 years old and were followed for a 10-year duration. Though the absolute change was not large, the baseline blood pressure was already optimal for both groups, so it is impressive to see a significant change.

In conclusion, nighttime can be scary for high blood pressure and its cardiovascular complications, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References: (1) Health Stat Report 2011. (2) CDC.gov. (3) Diabetes Care 2011;34 Suppl 2:S308-312. (4) uptodate.com. (5) BMC Fam Pract 2015;16(26). (6) J Am Coll Cardiol 2015;65(4):327-335. (7) J Am Coll Cardiol 2015;65(4):327-335. (8) Eur Heart J 2015;35(46):3304-3312. (9) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (10) J Acad Nutr Diet 2015;115(3):369-377. (11) JAMA Pediatr online April 27, 2015.

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, visit www.medicalcompassmd.com or consult your personal physician.

Mediterranean Diet
Can we overcome our genes?

By David Dunaief, M.D.

Dr. David Dunaief

We have made great strides in the fight against heart disease, yet it remains the number one cause of death in the United States. Approximately one-third of Americans over the age of 35 will die of heart disease (1). I hope this statistic has captured your attention, because it should. What is causing or contributing to such high numbers of heart disease deaths: genetics, environment or both? Many of us have the propensity toward heart disease. Can we alter this course, or is it our destiny?

A 2013 study, involving the Paleo-type diet and other ancient diets, suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce risk factors greatly. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (2). Let’s look at the evidence.

Genetic components

In a study published online in The Lancet, researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (3). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian but rather involved significant amounts of animal protein: fish and/or cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It seems to coordinate with modern times.

Interestingly, but not surprisingly, the average age of death was 43. The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease — some more than others — but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that we do not know it based on this study, which was not meant to provide the validity of the Paleo-type diet, but whether atherosclerosis is part of the normal aging process. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, potentially by following a Mediterranean-type diet with an emphasis on a plant-rich approach.

Mediterranean-type diet

A study about the Mediterranean-type diet and its potential positive impact on cardiovascular disease risk was published in the New England Journal of Medicine (4). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, with end points including heart attacks, strokes and mortality, compared to the low-fat diet. This improvement in risk profile occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and potentially wine. I call them “the Mediterranean diet with opulence,” because both groups consuming this diet had either significant amount of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day) and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease. The high-risk population included those with high blood pressure (80 percent of the population), diabetes and those who were overweight and/or were smokers.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and the standard American diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two diametrically opposed opinions, split by field. You may be surprised by which group liked it and which did not. Cardiologists hailed the study as a great achievement. They included Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D. They emphasized that now there is a large RCT measuring clinical outcomes, such as heart attacks, stroke and death.

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (5, 6). Ornish actually showed a reversal of atherosclerosis in one of his studies (7).

So which group of physicians is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more strict diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

Thus, even with a genetic proclivity toward cardiovascular disease, we can very much alter our destinies. The degree depends on the willingness of the participants. Potentially, we can have an impact that ranges from reduction to reversal.

References: (1) Circulation. 2008;117(4):e25. (2) www.uptodate.com. (3) The Lancet. 2013;Mar 11. (4) N Engl J Med. Online 2013;Feb 25. (5) J Fam Pract. 1995;41(6):560-568. (6) Am J Cardiol. 2011;108:498-507. (7) JAMA. 1998 Dec 16;280(23):2001-2007.

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, visit www.medicalcompassmd.com or consult your personal physician.

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