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Exercise, especially endurance-based, can reduce your risk of forming gallstones. Stock photo
Weight and inactivity are among the greatest risk factors

By David Dunaief, M.D.

Dr. David Dunaief

Gallstones affect up to 20 million Americans between the ages of 20 and 74, with a more than two times increased occurrence in women than in men, according to the NHANES III survey (1). There are two types of gallstones, 80 percent of which are cholesterol stones and 20 percent of which are pigment stones.

Common symptoms

Gallstones may be asymptomatic; however, when gallstones block either the cystic or common bile ducts, symptoms occur. Symptoms include dull or crampy abdominal pain that is exacerbated by meals and lasts one to five hours. Jaundice, which includes yellowing of skin and eyes, is another symptom. Others include nausea and vomiting, rapid heart rate, hypotension (low blood pressure) and fever (2).

Tests used for diagnosis

Blood tests include complete blood count, where there may be a rise in white blood cells; liver enzymes; and the pancreatic enzymes lipase and amylase. Diagnostic tests that have more accuracy are the endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP); however, these are invasive. Less accurate but noninvasive tests include abdominal X-ray, ultrasound and CAT scan (CT). The tests used also depend on where the stone may be located. Hepatobiliary (HIDA) scans are accurate if the stone is located in the cystic duct. And magnetic resonance retrograde cholangiopancreatography (MRCP) is used if the stone is thought to be located in the common bile duct (2).

What are the risk factors?

There are a multitude of risk factors. Some of these are modifiable, others are not. The modifiable ones include obesity, measured by body mass index (BMI); rapid weight loss; fat consumption; hormone replacement therapy (HRT); oral contraceptives; decreased physical activity; Crohn’s disease; and certain drugs. One nonmodifiable risk factor is age; the older we get, the higher the risk, with age 40 being the demarcation line (3). Other risk factors are gender, with females being more predisposed; pregnancy; and family history (4).

Let’s look at the evidence.

Obesity risks

Obesity may play an important role. The reason obesity is implicated is potentially due to bile becoming supersaturated (5). Bile is a substance produced in the liver and stored in the gallbladder. Bile aids in the digestion or breakdown of fats in the small intestines. Crystals may form, creating cholesterol gallstones from the bile.

Body mass index

A body mass index of greater than 30 kg/m² is considered obese. In a meta-analysis of two prospective, forward-looking observational trials, Copenhagen General Population Study and the Copenhagen City Heart Study, those in the highest quintile of BMI were almost three times as likely to experience symptomatic gallstones compared to those who were in the lowest quintile (6). The highest quintile was those who had a mean BMI of 32.5 kg/m² and thus were obese, whereas those in the lowest quintile had a mean BMI of 20.9 kg/m². This is a comparison of obese to ideal BMI. Not surprisingly, since women in general have a higher risk of gallstones, they also have a higher risk when their BMI is in the obese range compared to men, a 3.36-fold increase and 1.51-fold increase, respectively.

Also, the research showed that for every 1 kg/m² increase in BMI, there was a 7 percent increase in the risk of gallstones. Those who had genetic variants that increased their likelihood of an elevated BMI had an even greater increase in gallstone risk —17 percent — per 1 kg/m². In the study population of approximately 77,000, more than 4,000 participants became symptomatic for gallstones.

Physical activity

In the Physicians’ Health Study, a prospective observational trial, those in the lowest quintile of activity between the ages of 40 and 64 had a 72 percent increased risk of gallstone formation, and those 65 and older had a 33 percent increased risk (7). Also, men who were 65 and older and watched television more than six hours a week were at least three times as likely to have gallstones as those who watched fewer hours. There was a substantial increased risk for those under 65, as well, though to a slightly lesser degree.

Diabetes rears its ugly head

Just like with obesity, diabetes is almost always a culprit for complications. In a prospective observational study, those with diabetes were at a significant 2.55 times greater risk of developing gallstones than those without (8). Again, women had a higher propensity than men, but both had significant increases in the risk of gallstone formation, 3.85 times and 2.03 times, respectively. There were almost 700 participants in this study. The researchers believe that an alteration in glucose (sugar) metabolism may create this disease risk.

Hormone replacement therapy

If you needed another reason to be leery of hormone replacement therapy (HRT), then gallstones might be it. In a prospective observational trial, women who used HRT, compared to those who did not, had a 10 percent increased risk in cholecystectomy — removal of the gallbladder — to treat gallstones (9). Though this may not sound like a large increase, oral HRT increased the risk 16 percent, and oral estrogen-only therapy without progestogens increased the risk the most, 38 percent. Transdermal HRT did not have a significantly increased risk.

It is never too early or too late to treat obesity before it causes, in this case, gallstones. With a lack of exercise, obesity is exacerbated and, not surprisingly, so is symptomatic gallstone formation. Diabetes needs to be controlled to prevent complications. HRT, unless menopausal symptoms are unbearable, continues to show why it may not be a good choice.

References:

(1) Gastroenterology. 1999;117:632. (2) emedicine.medscape.com. (3) J Hepatol. 1993;18 Suppl 1:S43. (4) uptodate.com. (5) Best Pract Res Clin Gastroenterol. 2014 Aug;28:623-635. (6) Hepatology. 2013 Dec;58:2133-2141. (7) Ann Intern Med. 1998;128:417. (8) Hepatology. 1997;2:787. (9) CMAJ. 2013;16;185:549-550.

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.  

Steroids can be helpful but in moderation. Stock photo
Studies suggest shorter duration treatments can be as effective, with fewer side effects

By David Dunaief, M.D.

Dr. David Dunaief

Steroids typically make headlines related to their use as a performance-enhancing drug in sports. However, if we look beyond the flashy headlines, we see that corticosteroids, or steroids, play an important role in medicine.

Medical use

Steroids have an anti-inflammatory effect. This is critical since many acute and chronic diseases are based at least partially on inflammation. Chronic diseases that benefit include allergic, inflammatory and immunological diseases (1). These types of diseases touch on almost every area of the body, from osteoarthritis and autoimmune diseases to asthma, COPD (emphysema and chronic bronchitis) and eye disorders.

Steroids are delivered orally, topically as creams, lotions and eye drops, or via injections, intravenous solutions and inhaled formulations. The most commonly known medication is prednisone, but there are many others, including prednisolone, methylprednisolone, cortisone, hydrocortisone and dexamethasone.

Their benefits can be tremendous, improving functionality and reducing pain or improving breathing. You could say they are lifesaving in some instances, and with rescue inhalers they may just be that.

The bad

However, there is a very big caveat: They come at a price. Steroids cause weight gain, increased glucose (sugars), high blood pressure, cardiovascular events, osteoporosis, change in mood (psychoses), cataracts, glaucoma, infection, peptic ulcers, Cushing’s syndrome, and the list goes on. These are among the reasons medical professionals recommend using the least amount for the shortest time.

The upshot

The good news is that a plant-based diet may have similar beneficial effects in chronic diseases as steroids without all the downsides. Let’s look at the evidence.

The role in pneumonia

Pneumonia is among the top-10 leading causes of death in the world (2). In a meta-analysis (a group of nine studies), there was no overall effect of corticosteroids in reducing the risk of mortality in community-acquired pneumonia (3). However, when the data was broken into subsets, the findings were different. In subset data of those who had severe pneumonia, there was a statistically significant 74 percent reduction in mortality. And when duration was the main focus in subgroup analysis, those who received prolonged use of steroids reduced their risk of mortality by half. 

Unfortunately, with the benefit comes an increased risk of adverse events, and this meta-analysis was no exception. There was a greater than two-times increased risk of abnormally high glucose levels with prolonged use. Thus, when giving steroids, especially for a prolonged use, it may be wise to check glucose levels.

In a randomized controlled trial (RCT), the gold standard of studies, results reinforced the beneficial effects of steroids on pneumonia. They showed that in those with both severe pneumonia and high inflammation, there was a two-thirds reduction in treatment failures when corticosteroids were added to the regimen (4). There were 120 patients involved in the study. They received antibiotics plus either methylprednisolone or placebo for five days.

Osteoarthritis: surprising results

As we know, osteoarthritis specifically of the knee is very common, and intra-articular (in the joint) injections directly into the knee are becoming routine treatment. A study compared injectable hyaluronic acid to injectable corticosteroid (5). The results showed that over three months, the corticosteroid was superior to hyaluronic acid in terms of reducing pain, 66 percent versus 43.8 percent, respectively. 

Interestingly, over the longer term, 12 months, hyaluronic acid reduced the pain and maintained its effect significantly longer than the steroid, 33 percent versus a meager 8.2 percent, respectively. Study groups received five injections of either steroid or of hyaluronic acid directly to the knee over a five-week period. Thus, steroids may not always be the most effective choice when it comes to pain reduction. Hyaluronic acid may have caused this beneficial effect by reducing inflammation, protecting cartilage and preventing cell death, according to the authors.

COPD: Length may not matter

It is not unusual to treat COPD patients with oral steroids. But what is the proper duration? The treatment paradigm has been two weeks with 40 mg of corticosteroids daily. However, results in an RCT of 600 patients showed that five days with 40 mg of corticosteroid was equivalent to 14 days of the same dosage and frequency (6). The hope is that the shorter use of steroids will mean fewer side effects. We have come a long way; prior to 1999, eight weeks of steroids was a more commonplace approach to treating acute COPD exacerbations.

Dietary effect

One of the great things about steroids is that they reduce inflammation, and we know that the basis of greater than 80 percent of chronic disease is inflammation. A plant-based diet involving lots of vegetables and fruits and some grains may have a similar effect as steroids, but without the side effects. The effect may be to modify the immune system and reduce inflammation (7).

The bioactive substances from plants thought to be involved in this process are predominantly carotenoids and the flavonoids. Thus, those patients who respond even minimally to steroids are likely to respond to a plant-based diet in much the same beneficial way without the downsides of a significant number of side effects. Diet, unlike steroids, can be used for a long duration and a high intake, with a direct relationship to improving disease outcomes.

In conclusion, it is always better to treat with the lowest effective dose for the shortest effective period when it comes to steroids. The complications of these drugs are enumerable and must always be weighed against the benefits. Sometimes, other drugs may have more beneficial effects over the long term, such as hyaluronic acid injections for knee osteoarthritis. A plant-based diet, with anti-inflammatory properties similar to steroids, may be a useful alternative for chronic disease or may be used alongside these drugs, possibly reducing their dosage and duration.

References:

(1) uptodate.com. (2) N Engl J Med. 1995;333(24):1618-1624. (3) PLoS One. 2012;7(10):e47926. (4) JAMA. 2015;313(7):677-686. (5) Open Access Rheum 2015;7:9-18. (6) JAMA. 2013;309(21):2223-2231. (7) Int J Vitam Nutr Res. 2008 Dec;78(6):293-298.

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.   

Think twice before running out and getting a cup of coffee if you have AFib. Stock photo
The role of caffeine is still in question

By David Dunaief, M.D.

Dr. David Dunaief

Atrial fibrillation (AFib) is a common arrhythmia, an abnormal or irregular heartbeat. Though there are several options, including medications and invasive procedures, treatment mostly boils down to symptomatic treatment, rather than treating or reversing underlying causes.

What is AFib? It is an electrical malfunction that affects the atria, the two upper chambers of the heart, causing them to beat “irregularly irregular.” This means there is no set pattern that affects the rhythm and potentially causes a rapid heart rate. The result of this may be insufficient blood supply throughout the body.

Complications that may occur can be severely debilitating, such as stroke or even death. AFib’s prevalence is expected to more than double by 2030 (1). Risk factors include age (the older we get, the higher the probability), obesity, high blood pressure, premature atrial contractions and diabetes.

AFib is not always symptomatic; however, when it is, symptoms include shortness of breath, chest discomfort, light-headedness, fatigue and confusion. This arrhythmia can be diagnosed by electrocardiogram (ECG), but more likely with a 24-hour Holter monitor. The challenge in diagnosing AFib is that it can be intermittent.

There may be a better way to diagnose AFib. In a study, the Zio Patch, worn for 14 days, was more likely to show arrhythmia than a 24-hour Holter monitor (2). The Zio Patch is a waterproof adhesive patch on the chest, worn like a Band-Aid, with one ECG lead.

There are two main types of AFib, paroxysmal and persistent. Paroxysmal is acute, or sudden, and lasts for less than seven days, usually less than 24 hours. It tends to occur with greater frequency over time, but comes and goes. Persistent AFib is when it continues past seven days (3). AFib is a progressive disease, meaning it gets worse, especially without treatment.

Medications are meant to treat either the rate or rhythm or prevent strokes from occurring. Those that treat rate include beta blockers, like metoprolol, and calcium channel blockers, such as diltiazem (Cardizem). Examples of medications that treat rhythm are amiodarone and sotalol. Then there are anticoagulants that are meant to prevent stroke, such as warfarin and some newer medications, dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). The newer anticoagulants are easier to administer but may have higher bleeding risks, in some circumstances with no antidote.

There is also ablation, an invasive procedure that requires threading a catheter through an artery, usually the femoral artery located in the groin, to reach the heart. In one type of ablation, the inappropriate nodes firing in the walls of the atria are ablated, or destroyed, using radiofrequency. This procedure causes scarring of atrial tissue. When successful, patients may no longer need medication.

The role of obesity

There is good news and bad news with obesity in regards to AFib. Let’s first talk about the bad news. In studies, those who are obese are at significantly increased risk. In the Framingham Heart Study, the risk of developing AFib was 52 percent greater in men who were obese and 46 percent greater in women who were obese when compared to those of normal weight (4). Obesity is defined as a BMI >30 kg/m², and normal weight as a BMI <25 kg/m². There were over 5,000 participants in this study with a follow-up of 13 years. The Danish Diet, Cancer and Health Study reinforces these results by showing that obese men were at a greater than twofold increased risk of developing AFib, and obese women were at a twofold increased risk (5).

Now the good news: Weight loss may help reduce the frequency of AFib episodes. That’s right; weight loss could be a simple treatment for this very dangerous arrhythmia. In a randomized controlled trial of 150 patients, those in the intervention group lost significantly more weight, 14 kg (32 pounds) versus 3.6 kg (eight pounds), and saw a significant reduction in atrial fibrillation severity score (AFSS) compared to those in the control group (6).

AFSS includes duration, severity and frequency of atrial fibrillation. All three components in the AFSS were reduced in the intervention group compared to the control group. There was a 692-minute decrease in the time spent in AFib over 12 months in the intervention arm, whereas there was a 419-minute increase in the time in AFib in the control group. These results are potentially very powerful; this is the first study to demonstrate that managing risk factors may actually help manage the disease.

Caffeine

According to a meta-analysis (a group of six population-based studies) done in China, caffeine does not increase, and may even decrease, the risk of AFib (7). The study did not reach statistical significance. The authors surmised that drinking coffee on a regular basis may be beneficial because caffeine has antifibrosis properties. Fibrosis is the occurrence of excess fibrous tissue, in this case, in the atria. Atrial fibrosis could be a preliminary contributing step to AFib. Since these were population-based studies, only an association can be made with this discovery, rather than a hard and fast link. Still, this is a surprising result.

However, in those who already have AFib, it seems that caffeine may exacerbate the frequency of symptomatic occurrences, at least anecdotally. With my patients, when we reduce or discontinue substances that have caffeine, such as coffee, tea and chocolate, the number of episodes of AFib seems to decline. I have also heard similar stories from my colleagues and their patients. So, think twice before running out and getting a cup of coffee if you have AFib. What we really need are randomized controlled studies done in patients with AFib, comparing people who consume caffeine regularly to those who have decreased or discontinued the substance.

The bottom line is this: If there were ever a reason needed for obese patients to lose weight, treating atrial fibrillation should be on the top of the list, especially since it is such a dangerous disease with severe potential complications.

References:

(1) Am J Cardiol. 2013 Oct. 15;112:1142-1147. (2) Am J Med. 2014 Jan.;127:95.e11-7. (3) Uptodate.com. (4) JAMA. 2004;292:2471-2477. (5) Am J Med. 2005;118:489-495. (6) JAMA. 2013;310:2050-2060. (7) Canadian J Cardiol online. 2014 Jan. 6.

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. 

Significantly decreasing red meat consumption may be one solution for combatting iron overload. Stock photo
Excess iron may contribute to diabetes, eye disease and cardiovascular disease

By David Dunaief, M.D.

Dr. David Dunaief

When we think of iron, we associate it with reducing fatigue and garnering energy. Therefore, the more we get, the better, right? For many of us, this presumption is not grounded in reality.

Iron plays an integral role in such processes as DNA synthesis and adenosine triphosphate (ATP) production, which provides energy for cells (1). Therefore, it’s important to maintain iron homeostasis, or balance.

Iron in excess amounts may contribute to a host of diseases, including diabetes, diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, Parkinson’s disease and even heart disease. These diseases are perpetuated because, when we have excess iron, it may cause free radicals, which cause breakdown of DNA and tissues, ironically, the very things that iron homeostasis tends to preserve (2).

Significantly decreasing red meat consumption may be one solution for combatting iron overload. Stock photo

What helps us differentiate between getting enough iron and iron overload? It depends on the type of iron we ingest. There are two main types: heme iron and nonheme iron. Dietary heme, or blood, iron primarily comes from red meat and is easily absorbed into the gut. Dietary nonheme iron comes from other sources, such as plants and fortified foods, which are much more difficult sources to absorb. By focusing on the latter source of dietary iron, you may maintain homeostasis, since the gut tends to absorb 1 to 2 mg of iron but also excretes 1 to 2 mg of iron through urine, feces and perspiration.

Not only does it matter what type of iron we consume but also the population that ingests the iron. Age and gender are critical factors. Let me explain. Women of reproductive age, patients who are anemic and children may require more iron. However, iron overload is more likely to occur in men and postmenopausal women because they cannot easily rid the body of excess iron.

Let’s investigate some of the research that shows the effects of iron overload on different chronic diseases.

Impact on diabetes

In a meta-analysis (a group of 16 studies), results showed that both dietary heme iron and elevated iron storage (ferritin) may increase the risk of type 2 diabetes (3). When these ferritin levels were high, the risk of diabetes increased 66 to 129 percent. With heme iron, the group with the highest levels had a 39 percent increased risk of developing diabetes. There were over 45,000 patients in this analysis. You can easily measure ferritin with a simple blood test. These levels are modifiable through blood donation and avoidance of heme iron, thus reducing the risk of iron overload.

Diabetic retinopathy

Diabetic retinopathy is a complication of diabetes that occurs when glucose, or sugar, levels are not tightly controlled. Iron excess and its free radicals can have detrimental effects on the retina, or the back of the eye (4). This is potentially caused by oxidative stress resulting in retinal tissue damage (5).

So how does iron relate to uncontrolled glucose levels? In vitro studies (preliminary lab studies) suggest that high glucose levels may perpetuate the breakdown of heme particles and subsequently raise the level of iron in the eye (6). In fact, those with diabetic retinopathy tend to have iron levels that are 150 percent greater than those without the disease (7). Diets that are plant-based and nutrient-dense are some of the most effective ways to control glucose levels and avoid diabetic retinopathy.

Age-related macular degeneration

Continuing with the theme of retinal damage, excessive dietary iron intake may increase the risk of AMD according to the Melbourne Collaborative Cohort Study (8). AMD is the number one cause of blindness for people 65 and older. People who consumed the most iron from red meat increased their risk of early AMD by 47 percent. However, due to the low incidence of advanced AMD among study participants, the results for this stage were indeterminate.

I have been frequently asked if unprocessed red meat is better than processed meat. This study showed that both types of red meat were associated with an increased risk. This was a large study with over 5,000 participants ranging in age from 58 to 69.

Cardiovascular disease

Though we have made considerable headway in reducing the risk of cardiovascular disease and even deaths from these diseases, there are a number of modifiable risks that need to be addressed. One of these is iron overload.

In the Japan Collaborative Cohort, results showed that men who had the highest amount of dietary iron were at a 43 percent increased risk of stroke death, compared to those who ate the least amounts (9). And overall increased risk of cardiovascular disease death, which includes both heart disease and stroke, was increased by 27 percent in men who consumed the most dietary iron. Over 23,000 Japanese men between the ages of 40 to 79 were involved in this study.

In conclusion, we should focus on avoiding heme iron, especially for men and postmenopausal women. Too much iron creates a plethora of free radicals that damage the body. Therefore, the best way to circumvent the increased risk of chronic diseases with iron overload is prevention. Significantly decreasing red meat consumption and donating blood on a quarterly basis, assuming that one is not anemic, may be the most effective strategies for not falling into the trap of iron overload.

References:

(1) Proc  Natl  Acad  Sci USA. 1997;94:10919-10924. (2) Clin Haematol. 1985;14(1):129. (3) PLoS One. 2012;7(7):e41641. (4) Methods Enzymol. 1990;186:1-85. (5) Rev Endocr Metab Disord. 2008;9(4):315-327. (6) Biophys Chem. 2003;105:743-755. (7) Indian J Ophthalmol. 2004;52:145-148. (8) Am J Epidemiol. 2009;169(7):867-876. (9) J Epidemiol. 2012;22(6):484-493. Epub 2012 Sept 15.

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. 

Men are more than four times more likely to have an AAA. Stock photo
Inflammation and oxidative stress may play a role

By David Dunaief, M.D.

Dr. David Dunaief

Aneurysms are universally feared; they can be lethal, and most times they have no symptoms. There are numerous types of aneurysms, most of which are named by their location of occurrence, including abdominal, thoracic and cerebral (brain). In this article, I will discuss abdominal aortic aneurysms, better known as a “triple-A,” or AAA. Preventing any type of aneurysm should be a priority.

What is an AAA? It is an increase in the diameter of the walls of the aorta in one area, in this case, the abdomen. The aorta is the “water main” for supplying blood to the rest of the body from the heart. Abnormal enlargement weakens the walls and increases the risk that it may rupture. If the aorta ruptures, it causes massive hemorrhaging, or bleeding, and creates a substantial likelihood of death.

The exact incidence of aneurysms is difficult to quantify, since some people may die due to its rupture without having an autopsy; however, estimates suggest that they occur in 4 to 9 percent of the population (1). Fortunately, there are possible interventions if they are caught before they rupture.

The cause of AAA is not known, but it is thought that inflammation and oxidative stress play an important role in weakening smooth muscle in the aorta (2).

People who are at highest risk for aneurysms are those over age 60 (3). Other risk factors include atherosclerosis, or hardened arteries, high blood pressure, race (Caucasian), gender (male), family history, smoking and having a history of aneurysms in other arteries (4). Some of these risk factors are modifiable, such as atherosclerosis, high blood pressure and smoking.

Men are more than four times more likely to have an AAA (5). Though males are at a higher risk, women are at a higher risk of having an AAA rupture (6).

Is it important to get screened?

Yes, it is important, especially if you have risk factors. Although some people do experience nondescript symptoms, such as pain in the abdomen, back or flank pain, the majority of cases are asymptomatic (4). A smaller AAA is less likely to rupture and can be monitored closely with noninvasive diagnostic tools, such as ultrasound and CT scan.

Sometimes cost is a question when it comes to screening, but one study showed unequivocally that screening ultimately reduces cost, because of the number of aneurysms that are identified and potentially prevented from rupturing (7).

What are the treatments?

There are no specific medications that prevent or treat abdominal aortic aneurysms directly. Medications for treating risk factors, such as high blood pressure, have no direct impact on an aneurysm’s size or progression. But the mainstay of treatment is surgery to prevent rupture.

When to watch and wait and when to treat is a difficult question; surgery is not without its complications, and risk of death is higher than many other surgeries. AAA size is the most important factor. In women, AAAs over 5.0 cm may need immediate treatment, while in men, those over 5.5 cm may need immediate treatment (8). Smaller AAAs, however, are trickier.

The growth rate is important, so patients with this type of aneurysm should have an ultrasound or CT scan every six to 12 months. If you have an aneurysm, have a discussion with your physician about this.

Lifestyle changes

One of the most powerful tools against AAA is prevention; it avoids the difficult decision of how to best avoid rupture and the complications of surgery itself. Lifestyle changes are a must. They don’t typically have dangerous side effects, but rather potential side benefits. These lifestyle changes include smoking cessation, exercise and dietary changes.

Smoking cessation

Smoking has the greatest impact because it directly impacts the occurrence and size of an AAA. It increases risk of medium-to-large size aneurysms by at least fivefold. One study found that smoking was responsible for 78 percent of aortic aneurysms larger than 4 cm (9). Remember, size does matter in terms of rupture risk. So, for those who smoke, this is a wake-up call.

Impact of fruit

A simple lifestyle modification with significant impact is increasing your fruit intake. The results of two prospective (forward-looking) study populations, Cohort of Swedish Men and the Swedish Mammography Cohort Study, showed that consumption of greater than two servings of fruit a day decreased the risk of an AAA by 25 percent (10). If you do have an AAA, this same amount of fruit also decreased the risk of AAA rupture by 43 percent. This study involved over 80,000 men and women, ages 46 to 84, with a follow-up of 13 years.

The authors believe that fruit’s impact may have to do with its antioxidant properties; it may reduce the oxidative stress that can cause these types of aneurysms. Remember, the quandary has been when the benefit of surgery outweighs the risks, in terms of preventing rupture. This modest amount of fruit on a daily basis may help alleviate this quandary.

So, what have we learned? Screening for AAA may be very important, especially as we age and if we have a family history. To reduce your risk, lifestyle changes, including smoking cessation and increased fruit intake, are no-brainers.

References:

(1) Ann Intern Med. 2001;134(3):182. (2) Arterioscler Thromb Vasc Biol. 2007;27:461–469. (3) J Vasc Surg. 1999;30(6):1099. (4) uptodate.com. (5) Arch Intern Med. 2000;160(10):1425. (6) J Vasc Surg. 2006;43(2):230. (7) 2012 BMJ Publishing Group. (8) Lancet. 1998;352(9141):1649. (9) Ann Intern Med. 1997;126(6):441. (10) Circulation. 2013;128:795-802.

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.         

Stock photo
Lifestyle changes put you in control

By David Dunaief, M.D.

Dr. David Dunaief

Even though cardiovascular disease has been on the decline, it is still the number one killer of Americans, responsible for almost 30 percent of deaths per year (1). Let’s start with a quiz of your cardiovascular disease IQ. The questions below are either true or false. The answers and evidence are provided after.

1. Fish oil supplements help reduce the risk of cardiovascular disease and mortality.

2. Fiber has significant beneficial effects on heart disease prevention.

3. Unlike sugary sodas and drinks, diet soda is most likely not a contributor to this disease.

4. Vitamin D deficiency may contribute to cardiovascular disease.

Now that was not so difficult. Or was it? The answers are as follows: 1-F, 2-T, 3-F, 4-T. Regardless of whether you know the answers, the reasons are even more important to know. Let’s look at the evidence.

Fish oil

There is a whole industry built around fish oil and reducing the risk of cardiovascular disease. Yet the data don’t seem to confirm this theory. In the age-related eye disease study 2 (AREDS2), unfortunately, 1 gram of fish oil (long chain omega-3 fatty acids) daily did not demonstrate any benefit in the prevention of cardiovascular disease nor its resultant mortality (2). This study was done over a five-year period in the elderly with macular degeneration. The cardiovascular primary endpoint was a tangential portion of the ophthalmic AREDS2. This does not mean that fish, itself, falls into that same category, but for now there does not seem to be a need to take fish oil supplements for heart disease, except potentially for those with very high triglycerides. Fish oil, at best, is controversial; at worst, it has no benefit with cardiovascular disease.

Fiber

We know that fiber tends to be important for a number of diseases, and cardiovascular disease does not appear to be an exception. In a meta-analysis involving 22 observational studies, the results showed a linear relationship between fiber intake and a decreased risk for developing cardiovascular disease (3). In other words, for every 7 grams of fiber consumed, there was a 9 percent reduced risk of developing the disease. It did not matter the source of the fiber from plant foods; vegetables, grains and fruit all decreased the risk of cardiovascular disease. This did not involve supplemental fiber, like that found in Fiber One or Metamucil. To give you an idea about how easy it is to get a significant amount of fiber, one cup of lentils has 15.6 grams of fiber, one cup of raspberries or green peas has almost 9 grams and one medium-size apple has 4.4 grams. Americans are sorely deficient in fiber (4).

Diet soda

Analysis of the Northern Manhattan study, a population-based study of 4,400 adults in New York City suggests that daily diet soda intake may increase the risk of heart disease and other cardiovascular events, such as stroke (5). In those drinking diet soda daily, there was an increased likelihood they experienced a cardiovascular event, such as a stroke or heart attack during the study period. These results took into account confounding factors like smoking, diabetes, high blood pressure and obesity. Interestingly, the same effect was not found with lower levels of diet soda or sugared soda consumption.

Vitamin D

The results of an observational study in the elderly suggest that vitamin D deficiency may be associated with cardiovascular disease risk. The study showed that those whose vitamin D levels were low had increased inflammation, demonstrated by elevated biomarkers including C-reactive protein (CRP) (6). This biomarker is related to inflammation of the heart, though it is not as specific as one would hope.

What have we learned?

Study after study has shown benefit with fiber. So if you want to reduce the risk of cardiovascular disease, consume as much whole food fiber as possible. While the effects of diet soda are still being studied, early results suggest we should limit or eliminate our intake. Also, since we live in the Northeast, consider taking at least 1,000 IUs of vitamin D daily. This is a simple way to help thwart the risk of the number one killer.

References:

(1) hhs.gov. (2) JAMA Intern Med. Online March 17, 2014. (3) BMJ 2013; 347:f6879. (4) Am J Med. 2013 Dec;126(12):1059-67.e1-4. (5) J Gen Intern Med. 2012 Sep;27(9):1120-6. (6) J Clin Endocrinol Metab online February 24, 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. 

Aerobic exercise and weight lifting may prevent cognitive decline, according to studies. Stock photo
Reducing carbohydrate and sugar intake may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

Mild cognitive impairment (MCI) is one of the more common disorders that occurs as we age. But age is not the only determinant. There are a number of modifiable risk factors. MCI is feared, not only for its own challenges but also because it may lead to dementia, with Alzheimer’s disease and vascular dementia being the more common forms. Prevalence of MCI may be as high as one in five in those over age 70 (1). It is thought that those with MCI may have a 10 percent chance of developing Alzheimer’s disease (2).

Since there are very few medications presently that help prevent cognitive decline, the most compelling questions are: What increases risk and what can we do to minimize the risk of developing cognitive impairment?

Many chronic diseases and disorders contribute to MCI risk. These include diabetes, heart disease, Parkinson’s disease and strokes. If we can control these maladies, we may reduce the risk of cognitive decline. We know that we can’t stop aging, but we can age gracefully.

Heart disease’s impact

In an observational study, results demonstrated that those suffering from years of heart disease are at a substantial risk of developing MCI (3). The study involved 1,450 participants who were between the ages of 70 and 89 and were not afflicted by cognitive decline at the beginning of the study. Patients with a history of cardiac disease had an almost two times greater risk of developing nonamnestic MCI, compared to those individuals without cardiac disease. Women with cardiac disease were affected even more, with a three times increased risk of cognitive impairment.

Nonamnestic MCI affects executive functioning — decision-making abilities, spatial relations, problem-solving capabilities, judgments and language. It is a more subtle form of impairment that may be more frustrating because of its subtlety. It may lead to vascular dementia and may be a result of clots.

Stroke location vs. frequency

Not surprisingly, stroke may have a role in cognitive impairment. Stroke is also referred to as a type of vascular brain injury. But what is surprising is that in a study, results showed that the location of the stroke was more relevant than the frequency or the multitude of strokes (4). If strokes occurred in the cortical and subcortical gray matter regions of the brain, executive functioning and memory were affected, respectively. Thus, the locations of strokes may be better predictors of subsequent cognitive decline than the number of strokes. Clinically silent strokes that were found incidentally by MRI scans had no direct effect on cognition, according to the authors.

Exercise’s effects

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Exercise may play a significant role in preventing cognitive decline and possibly even improving MCI in patients who have the disorder. Interestingly, different types of exercise have different effects on the brain. Aerobic exercise may stimulate one type of neuronal development, while resistance training or weight lifting another.

In an animal study involving rats, researchers compared aerobic exercise to weight lifting (5). Weight lifting was simulated by attaching weights to the tails of rats while they climbed ladders. Both groups showed improvements in memory tests, however, there was an interesting divergence.

With aerobic exercise, the level of the protein BDNF (brain-derived neurotrophic factor) increased significantly. This is important because BDNF is involved in neurons and the connections among them, called synapses, related mostly to the hippocampus, or memory center. The rats that “lifted weights” had an increase in another protein, IGF (insulin growth factor), that promotes the development of neurons in a different area of the brain. The authors stressed the most important thing is to exercise, regardless of the type.

In another study that complements the previous study, women were found to have improved spatial memory when they exercised — either aerobic or weight lifting (6). Interestingly, verbal memory was improved more by aerobic exercise than by weight lifting. Spatial memory is the ability to recall where items were arranged, and verbal memory is the ability to recall words. The authors suggest that aerobic exercise and weight lifting affect different parts of the brain.

This was a randomized controlled trial that was six months in duration and involved women, ages 70 to 80, who had MCI at the trial’s start. There were three groups in the study: aerobic, weight lifting and stretching and toning. Those who did stretches or toning alone experienced deterioration in memory skills over the same period.

A Centers for Disease Control and Prevention report claims the majority of the adult population is woefully deficient in exercise: Only about one in five Americans exercise regularly, both using weights and doing aerobic exercise (7).

Diet’s effects

Several studies show that the Mediterranean diet helps prevent MCI and possibly prevents conversion from MCI to Alzheimer’s (8, 9). In addition, a study showed that high levels of carbohydrates and sugars, when compared to lower levels, increased the risk of cognitive decline by more than three times (5). The authors surmise that carbohydrates have a negative impact on insulin and glucose utilization in the brain.

Cognitive decline is a disorder that should be taken very seriously, and everything that can be done to prevent it should be utilized. Exercise has potentially positive effects on neuron growth and development, and controlling carbohydrate and sugar intake may reduce risk. Let’s not squander the opportunity to reduce the risk of MCI, a potentially life-altering disorder.

References:

(1) Ann Intern Med. 2008;148:427-434. (2) uptodate.com. (3) JAMA Neurol. 2013;70:374-382. (4) JAMA Neurol. 2013;70:488-495. (5) J Alzheimers Dis. 2012;32:329-339. (6) J Aging Res. 2013;2013:861893. (7) Morb Mortal Wkly Rep. 2013;62:326-330. (8) Neurology 2013;80:1684-1692. (9) Arch Neurol. 2009 Feb.;66:216-225.

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. 

Increasing the quality of food that you eat has a tremendous impact. Stock photo
Micronutrient-dense foods are most satisfying

By David Dunaief, M.D.

Dr. David Dunaief

Why do we eat? Hunger is only one reason. There are many psychological and physiological factors that influence our eating behavior, including addictions, lack of sleep, stress, environment, hormones and others. This can make weight management or weight loss for the majority who are overweight or obese — approximately 72 percent of the U.S. adult population — very difficult to achieve (1).

Since calorie counts have been required on some municipalities’ menus, we would expect that consumers would be making better choices. Unfortunately, studies of the results have been mostly abysmal. Nutrition labeling either doesn’t alter behavior or encourages higher calorie purchases, according to most studies (2, 3).

Does this mean we are doomed to acquiesce to temptation? Actually, no: It is not solely about willpower. Changing diet composition is more important.

What can be done to improve the situation? In my clinical experience, increasing the quality of food has a tremendous impact. Foods that are the most micronutrient dense, such as plant-based foods, rather than those that are solely focused on macronutrient density, such as protein, carbohydrates and fats, tend to be the most satisfying. In a week to a few months, one of the first things patients notice is a significant reduction in their cravings. But don’t take my word for it. Let’s look at the evidence.

Effect of refined carbohydrates

By this point, many of us know that refined carbohydrates are not beneficial. Well, there is a randomized controlled trial (RCT), the gold standard of studies, with results that show refined carbohydrates may cause food addiction (4). There are certain sections of the brain involved in cravings and reward that are affected by high-glycemic (sugar) foods, as shown by MRI scans of trial subjects.

The participants consumed a 500-calorie shake with either a high-glycemic index or with a low-glycemic index. They were blinded (unaware) as to which type they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. In fact, the region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number or quantity of calories consumed. Granted, this was a very small study, but it was well designed. High-glycemic foods include carbohydrates, such as white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates. The composition of calories matters.

Comparing macronutrients

We tend to focus on macronutrients when looking at diets. These include protein, carbohydrates and fats, but are these the elements that have the most impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among groups, nor was there much success in helping obese patients reduce their weight (5, 6). In fact, only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved an overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another relatively well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is defined as obese (at least 30 kg/m²).

Again, focusing primarily on macronutrient levels and calorie counts did very little to improve results.

Impact of obesity

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be lacking in micronutrients (7). The authors surmise that it may have to do with the change in metabolic activity associated with more fat tissue. These micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

However, supplements don’t compensate for missing micronutrients. Quite the contrary, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation. Please ask your doctor.

Steroid levels

The good news is that once people lose weight, they may be able to continue to keep the weight off. In a prospective (forward-looking) study, results show that once obese patients lose weight, the levels of cortisol metabolite excretion decreases significantly (8).

Why is this important? Cortisol is a glucocorticoid, which means it raises the level of glucose and is involved in mediating visceral or belly fat. This type of fat has been thought to coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality. This is an encouraging preliminary, yet small, study involving women.

Therefore, controlling or losing weight is not solely about willpower. Don’t use the calories on a menu as your sole criteria to determine what to eat; even if you choose lower calories, it may not get you to your goal. While calories may have an impact, the nutrient density of the food may be more important. Thus, those foods high in micronutrients may also play a significant role in reducing cravings, ultimately helping to manage weight.

References:

(1) www.cdc.gov. (2) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (3) Am J Prev Med.2011 Oct;41(4):434–438. (4) Am J Clin Nutr Online 2013;Jun 26. (5) N Engl J Med 2009 Feb 26;360:859. (6) N Engl J Med 2009 Feb 26;360:923. (7) Medscape General Medicine. 2006;8(4):59. (8) Clin Endocrinol.2013;78(5):700-705.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

Balance and strengthening exercises help to prevent falls. Stock photo
Our best line of defense is prevention

By David Dunaief, M.D.

Dr. David Dunaief

When we are young, falls usually do not result in significant consequences. However, when we reach middle age and chronic diseases become more prevalent, falls become more substantial. And, unfortunately, falls are a serious concern for older patients, where consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability and a decline in physical and social activities (1). Ultimately, falls can lead to loss of independence (2).

Of those over the age of 65, between 30 and 40 percent will fall annually (3). Most of the injuries that involve emergency room visits are due to falls in this older demographic (4).

What can increase the risk of falls?

Many factors contribute to fall risk. A personal history of falling in the recent past is the most prevalent. But there are many other significant factors, such as age, being female and using drugs, like antihypertensive medications used to treat high blood pressure and psychotropic medications used to treat anxiety, depression and insomnia.

Chronic diseases, including arthritis, as an umbrella term; a history of stroke; cognitive impairment; and Parkinson’s disease can also contribute. Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (5).

How do we prevent falls?

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Fortunately, there are ways to modify many risk factors and ultimately reduce the risk of falls. Of the utmost importance is exercise. But what do we mean by “exercise”? Exercises involving balance, strength, movement, flexibility and endurance, whether home based or in groups, all play significant roles in fall prevention (6). We will go into more detail below.

Many of us in the Northeast suffer from low vitamin D, which may strengthen muscle and bone. This is an easy fix with supplementation. Footwear also needs to be addressed. Nonslip shoes, if recent winters are any indication, are of the utmost concern. Inexpensive changes in the home, like securing area rugs, can also make a big difference.

Medications that exacerbate fall risk

There are a number of medications that may heighten fall risk. As I mentioned, psychotropic drugs top the list. Ironically, they also top the list of the best-selling drugs. But what other drugs might have an impact?

High blood pressure medications have been investigated. A propensity-matched sample study (a notch below a randomized control trial in terms of quality) showed an increase in fall risk in those who were taking high blood pressure medication (7). Surprisingly, those who were on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase. One would have expected those on the highest levels to have the greatest increase in risk, but this was not the case.

While blood pressure medications may contribute to fall risk, they have significant benefits in reducing the risks of cardiovascular disease and events. Thus, we need to weigh the risk-benefit ratio, specifically in older patients, before considering stopping a medication. When it comes to treating high blood pressure, lifestyle modifications may also play a significant role in treating this disease (8).

Why is exercise critical?

All exercise has value. A meta-analysis of a group of 17 trials showed that exercise significantly reduced the risk of a fall (9). If the categories are broken down, exercise had a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in those falls requiring medical attention. Even more impressive was a 61 percent reduction in fracture risk.

Remember, the lower the fracture risk, the more likely you are to remain physically independent. Thus, the author summarized that exercise not only helps to prevent falls but also fall injuries. The weakness of this study was that there was no consistency in design of the trials included in the meta-analysis. Nonetheless, the results were impressive.

Unfortunately, those who have fallen before, even without injury, often develop a fear that causes them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased risk of falling (10).

What specific types of exercise are useful?

Many times, exercise is presented as a word that defines itself. In other words: Just do any exercise and you will get results. But some exercises may be more valuable or have more research behind them. Tai chi, yoga and aquatic exercise have been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial, the gold standard of studies, showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (11). The aim of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the number of falls from a mean of 2.00 to a fraction of this level — a mean of 0.29. There was no change in the control group.

There was also a 44 percent decline in the number of patients who fell. This study’s duration was six months and involved 108 postmenopausal women with an average age of 58. This is a group that is more susceptible to bone and muscle weakness. Both groups were given equal amounts of vitamin D and calcium supplements. The good news is that many patients really like aquatic exercise.

Thus, our best line of defense against fall risk is prevention. Does this mean stopping medications? Not necessarily. But for those 65 and older, or for those who have “arthritis” and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before considering changing your BP medications, review the risk-to-benefit ratio with your physician. The most productive way to prevent falls is through lifestyle modifications.

References:

(1) MMWR. 2014;63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) J Gerontol. 1991;46(5):M16. (4) MMWR Morb Mortal Wkly Rep. 2003;52(42):1019. (5) JAMA. 1995;273(17):1348. (6) Cochrane Database Syst Rev. 2012;9:CD007146. (7) JAMA Intern Med. 2014 Apr;174(4):588-595. (8) JAMA Intern Med. 2014;174(4):577-587. (9) BMJ. 2013;347:f6234. (10) Age Ageing. 1997 May;26(3):189-193. (11) Menopause. 2013;20(10):1012-1019.

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. 

Cognitive behavioral therapy may improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Though statistics vary widely, about 30 percent of Americans are affected by insomnia, according to one frequently used estimate, and women tend to be affected more than men (1). Insomnia is thought to have several main components: difficulty falling asleep, difficulty staying asleep, waking up before a full night’s sleep and sleep that is not restorative or restful (2).

Unlike sleep deprivation, patients have plenty of time for sleep. Having one or all of these components is considered insomnia. There is debate about whether or not it is actually a disease, though it certainly has a significant impact on patients’ functioning (3).

Insomnia is frustrating because it does not necessarily have one cause. Causes can include aging; stress; psychiatric disorders; disease states, such as obstructive sleep apnea and thyroid dysfunction; asthma; medication; and it may even be idiopathic (of unknown cause). It can occur on an acute (short-term), intermittent or chronic basis. Regardless of the cause, it may have a significant impact on quality of life. Insomnia also may cause comorbidities (diseases), including heart failure.

Fortunately, there are numerous treatments. These can involve medications, such as benzodiazepines like Ativan and Xanax. The downside of these medications is they may be habit-forming. Nonbenzodiazepine hypnotics (therapies) include sleep medications, such as Lunesta (eszopiclone) and Ambien (zolpidem). All of these medications have side effects. We will investigate Ambien further because of its warnings.

There are also natural treatments, involving supplements, cognitive behavioral therapy and lifestyle changes.

Let’s look at the evidence.

Heart failure

Insomnia may perpetuate heart failure, which can be a difficult disease to treat. In the HUNT analysis (Nord-Trøndelag Health Study), an observational study, results showed insomnia patients had a dose-dependent response for increased risk of developing heart failure (4). In other words, the more components of insomnia involved, the higher the risk of developing heart disease.

There were three components: difficulty falling asleep, difficulty maintaining sleep and nonrestorative sleep. If one component was involved, there was no increased risk. If two components were involved, there was a 35 percent increased risk, although this is not statistically significant.

However, if all three components were involved, there was 350 percent increased risk of developing heart failure, even after adjusting for other factors. This was a large study, involving 54,000 Norwegians, with a long duration of 11 years.

What about potential treatments?

Ambien: While nonbenzodiazepine hypnotics may be beneficial, this may come at a price. In a report by the Drug Abuse Warning Network, part of the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of reported adverse events with Ambien that perpetuated emergency department visits increased by more than twofold over a five-year period from 2005 to 2010 (5). Insomnia patients most susceptible to significant side effects are women and the elderly. The director of SAMHSA recommends focusing on lifestyle changes for treating insomnia by making sure the bedroom is sufficiently dark, getting frequent exercise, and avoiding caffeine.

In reaction to this data, the FDA required the manufacturer of Ambien to reduce the dose recommended for women by 50 percent (6). Ironically, sleep medication like Ambien may cause drowsiness the next day — the FDA has warned that it is not safe to drive after taking extended-release versions (CR) of these medications the night before.

Magnesium: The elderly population tends to suffer the most from insomnia, as well as nutrient deficiencies. In a double-blinded, randomized controlled trial (RCT), the gold standard of studies, results show that magnesium had resoundingly positive effects on elderly patients suffering from insomnia (7).

Compared to a placebo group, participants given 500 mg of magnesium daily for eight weeks had significant improvements in sleep quality, sleep duration and time to fall asleep, as well as improvement in the body’s levels of melatonin, a hormone that helps control the circadian rhythm.

The strength of the study is that it is an RCT; however, it was small, involving 46 patients over a relatively short duration.

Cognitive behavioral therapy

In a study, just one 2½-hour session of cognitive behavioral therapy delivered to a group of 20 patients suffering from chronic insomnia saw subjective, yet dramatic, improvements in sleep duration from 5 to 6½ hours and decreases in sleep latency from 51 to 22 minutes (8). The patients who were taking medication to treat insomnia experienced a 33 percent reduction in their required medication frequency per week. The topics covered in the session included relaxation techniques, sleep hygiene, sleep restriction, sleep positions, and beliefs and obsessions pertaining to sleep. These results are encouraging.

It is important to emphasize the need for sufficient and good-quality sleep to help prevent, as well as not contribute to, chronic diseases, such as cardiovascular disease. While medications may be necessary in some circumstances, they should be used with the lowest possible dose for the shortest amount of time and with caution, reviewing possible drug-drug and drug-supplement interactions.

Supplementation with magnesium may be a valuable step toward improving insomnia. Lifestyle changes including sleep hygiene and exercise should be sought, regardless of whether or not medications are used.

References:

(1) Sleep. 2009;32(8):1027. (2) American Academy of Sleep Medicine, 2nd edition, 2005. (3) Arch Intern Med. 1998;158(10):1099. (4) Eur Heart J. online 2013;Mar 5. (5) SAMSHA.gov. (6) FDA.gov. (7) J Res Med Sci. 2012 Dec;17(12):1161-1169. (8) APSS 27th Annual Meeting 2013; Abstract 0555.