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David Dunaief

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Toenail fungus can have medical implications

By David Dunaief, M.D.

Dr. David Dunaief

Summer is almost here, and millions of Americans are beginning to expose their toes. Some are more self-conscious about it 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 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 also an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat, although it affects approximately 8 percent of the population (2). The risk factors are unclear but may 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 (3).

Many organisms can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A KOH (potassium hydroxide) preparation can be used to differentiate them. 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 psoriasis.

When considering treatment, 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. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Oral antifungals

There are several oral antifungal options, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These 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 toenail fungus with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration. 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 the 24-week group experiencing better results.

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.

Another approach to reducing side effects is to give oral antifungals in a pulsed fashion. In an 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, 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, it takes approximately a year of daily use, and its efficacy is not as great as 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 in patients with mild to moderate levels of fungus.

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. 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

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 (10). Partial improvement occurred in the toenails of 10 patients. 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.

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; and do appropriate precautionary tests on a regular basis, such as liver enzyme monitoring with terbinafine. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better choice. No matter what, 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) 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.       

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Being active is the magic pill for a healthy life. Stock photo
Inactivity may increase mortality and disease risk

By David Dunaief, M.D.

Dr. David Dunaief

With the advent of summer weather, with its heat and humidity, who wants to think about exercise? Instead, it’s tempting to lounge by the pool or even inside with air conditioning.

First, let me delineate between exercise and inactivity; they are not complete opposites. When we consider exercise, studies tend to focus on moderate to intense activity. However, light activity and being sedentary, or inactive, tend to get clumped together. But there are differences between light activity and inactivity.

Light activity may involve cooking, writing and strolling (1). Inactivity involves sitting, as in watching TV or in front of a computer screen. Inactivity utilizes between 1 and 1.5 metabolic equivalent units — better known as METS — a way of measuring energy. Light activity, however, requires greater than 1.5 METS. Thus, in order to avoid inactivity, we don’t have to exercise in the dreaded heat. We need to increase our movement.

What are the potential costs of inactivity? According to the World Health Organization, over 3 million people die annually from inactivity. This ranks inactivity in the top five of potential underlying mortality causes (2).

How much time do we spend inactive? In an observational study of over 7,000 women with a mean age of 71 years old, 9.7 waking hours were spent inactive or sedentary. These women wore an accelerometer to measure movements. Interestingly, as body mass index and age increased, the amount of time spent sedentary also increased (3).

Inactivity may increase the risk of mortality and plays a role in increasing risks for diseases such as heart disease, diabetes and fibromyalgia. It can also increase the risk of disability in older adults.

Surprisingly, inactivity may be worse for us than smoking and obesity. For example, there can be a doubling of the risk for diabetes in those who sit for long periods of time, compared to those who sit the least (4).

Let’s look at the evidence.

Does exercise overcome inactivity?

We tend to think that exercise trumps all; if you exercise, you can eat what you want and, by definition, you’re not sedentary. Right? Not exactly. Diet is important, and you can still be sedentary, even if you exercise. In a meta-analysis — a group of 47 studies — results show that there is an increased risk of all-cause mortality with inactivity, even in those who exercised (5). In other words, even if you exercise, you can’t sit for the rest of the day. The risk for all-cause mortality was 24 percent overall.

However, those who exercised saw a blunted effect with all-cause mortality, making it significantly lower than those who were inactive and did very little exercise: 16 percent versus 46 percent increased risk of all-cause mortality. So, it isn’t that exercise is not important, it just may not be enough to reduce the risk of all-cause mortality if you are inactive for a significant part of the rest of the day.

Worse than obesity?

Obesity is a massive problem in this country; it has been declared a disease, itself, and it also contributes to other chronic diseases. But would you believe that inactivity has more of an impact than even obesity? In an observational study, using data from the EPIC trial, inactivity might be responsible for two times as many premature deaths as obesity (6). This was a study involving 330,000 men and women.

Interestingly, the researchers created an index that combined occupational activity with recreational activity. They found that the greatest reduction in premature deaths (in the range of 16 to 30 percent) was between two groups, the normal weight and moderately inactive group versus the normal weight and completely inactive group. The latter was defined as those having a desk job with no additional physical activity. To go from the completely inactive to moderately inactive, all it took, according to the study, was 20 minutes of brisk walking on a daily basis.

So what have we learned about inactivity? If you are inactive, increasing your activity to be moderately inactive by briskly walking for 20 minutes a day may reduce your risk of premature death significantly. Even if you exercise the recommended 150 minutes a week, but are inactive the rest of the day, you may still be at risk for cardiovascular disease. You can potentially further reduce your risk of cardiovascular disease by increasing your activity with small additions throughout the day.

The underlying message is that we need to consciously move throughout the day, whether at work with a walk during lunch or at home with recreational activity. Those with desk jobs need to be most attuned to opportunities to increase activity. Simply setting a timer and standing or walking every 30 to 45 minutes may increase your activity levels and possibly reduce your risk.

References:

(1) Exerc Sport Sci Rev. 2008;36(4):173-178. (2) WHO report: https://bit.ly/1z7TBAF. (3) JAMA. 2013;310(23):2562-2563. (4) Diabetologia 2012; 55:2895-2905. (5) Ann Intern Med. 2015;162:123-132, 146-147. (6) Am J Clin Nutr. online Jan. 24, 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.   

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Hypothyroidism is a condition in which the thyroid gland is not able to produce enough thyroid hormone. Stock photo
Treatment doesn’t always result in weight loss
Dr. David Dunaief

By David Dunaief, M.D.

Many refer to hypothyroidism as a potential cause for weight gain and low energy. But do we really know what it is and why it is important?

The thyroid is a butterfly-shaped organ responsible for maintaining our metabolism. It sits at the base of the neck, just below the laryngeal prominence, or Adam’s apple. The prefix “hypo,” derived from Greek, means “under” (1). Therefore, hypothyroidism indicates an underactive thyroid and results in slowing of the metabolism.

Blood tests determine if a person has hypothyroidism. Items that are tested include thyroid stimulating hormone (TSH), which is usually increased, thyroxine (free T4) and triiodothyronine (free T3 or T3 uptake). Both of these last two may be suppressed (2).

There are two types of primary hypothyroidism: subclinical and overt. In the overt (more obvious) type, classic symptoms include weight gain, fatigue, thinning hair, cold intolerance, dry skin and depression, as well as the changes in all three thyroid hormones on blood tests mentioned above. In the subclinical, there may be less obvious or vague symptoms and only changes in the TSH. The subclinical can progress to the overt stage rapidly in some cases (3). Subclinical is substantially more common than overt; its prevalence may be as high as 10 percent of the U.S. population (4).

Potential causes or risk factors for hypothyroidism are medications, including lithium; autoimmune diseases, whether personal or in the family history; pregnancy, though it tends to be transient; and treatments for hyperthyroidism (overactive thyroid), including surgery and radiation.

The most common type of hypothyroidism is Hashimoto’s thyroiditis, where antibodies attack thyroid gland tissues (5). Several blood tests are useful to determine if a patient has Hashimoto’s: thyroid peroxidase (TPO) antibodies and antithyroglobulin antibodies.

Myths versus realities

I would like to separate the myths from the realities with hypothyroidism. Does treating hypothyroidism help with weight loss? Not necessarily. Is soy potentially bad for the thyroid? Yes. Does coffee affect thyroid medication? Maybe. Let’s look at the evidence.

Medications

Levothyroxine and Armour Thyroid are two main medications for hypothyroidism. The difference is that Armour Thyroid converts T4 into T3, while levothyroxine does not. Therefore, one medication may be more appropriate than the other, depending on the circumstance. T3 can also be given with levothyroxine, which is similar to using Armour Thyroid.

What about supplements?

A study tested 10 different thyroid support supplements; the results were downright disappointing, if not a bit scary (6). Of the supplements tested, 90 percent contained actual medication, some to levels higher than what are found in prescription medications. These supplements could cause toxic effects on the thyroid, called thyrotoxicosis. Supplements are not FDA-regulated; therefore, they are not held to the same standards as medications. There is a narrow therapeutic window when it comes to the appropriate medication dosage for treating hypothyroidism, and it is sensitive. Therefore, if you are going to consider using supplements, check with your doctor and tread very lightly.

Soy impact

In a randomized controlled trial, the treatment group that received higher amounts of soy supplementation had a threefold greater risk of conversion from subclinical hypothyroidism to overt hypothyroidism than those who received considerably less supplementation (7). According to this small, yet well-designed, study, soy has a negative impact on the thyroid. Therefore, those with hypothyroidism may want to minimize or avoid soy.

The reason that soy may have this negative impact was illustrated in a study involving rat thyrocytes (thyroid cells) (8). Researchers found that soy isoflavones, especially genistein, which are usually beneficial, may contribute to autoimmune thyroid disease, such as Hashimoto’s thyroiditis. They also found that soy may inhibit the absorption of iodide in the thyroid.

Weight loss

Wouldn’t it be nice if the silver lining of hypothyroidism is that, with medication to treat the disease, we were guaranteed to lose weight? In a retrospective study, results showed that only about half of those treated with medication for hypothyroidism lost weight (9). This was a small study, and we need a large randomized controlled trial to test it further.

WARNING: The FDA has a black box warning on thyroid medications — they should never be used as weight loss drugs (10). They could put a patient in a hyperthyroid state or worse, having potentially catastrophic results.

Coffee

Taking levothyroxine and coffee together may decrease the absorption of levothyroxine significantly, according to one study (11). It did not seem to matter whether they were taken together or an hour apart. This was a very small study involving only eight patients. Still, I recommend avoiding coffee for several hours after taking the medication.

There are two take-home points, if you have hypothyroid issues: Try to avoid soy products, and don’t think supplements that claim to be thyroid support and good for you are harmless because they are over the counter and “natural.” In my clinical experience, an anti-inflammatory, vegetable-rich diet helps improve quality of life issues, especially fatigue and weight gain, for those with Hashimoto’s thyroiditis.

References:

(1) dictionary.com. (2) nlm.nih.gov. (3) Endocr Pract. 2005;11:115-119. (4) Arch Intern Med. 2000;160:526-534. (5) mayoclinic.org. (6) Thyroid. 2013;23:1233-1237. (7) J Clin Endocrinol Metab. 2011 May;96:1442-1449. (8) Exp Biol Med (Maywood). 2013;238:623-630. (9) American Thyroid Association. 2013;Abstract 185. (10) FDA.gov. (11) Thyroid. 2008;18:293-301.

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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KEEP MOVING A regular program of walking can reduce stiffness and inflammation. Stock photo
A 10-pound weight loss reduces pain by 50 percent

By David Dunaief, M.D.

Dr. David Dunaief

Over 27 million people in the U.S. suffer from osteoarthritis (OA) (1). Osteoarthritis is insidious, developing over a long period of time. By nature, it is chronic. It is also 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). This 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).

Most of us either tolerate or actually enjoy walking. We have heard that walking can exacerbate OA symptoms; the pounding can be harsh on our joints, especially our knees. Well, maybe not. Walking actually may have benefits.

In the Multicenter Osteoarthritis Study (MOST), results showed that walking may indeed be useful to prevent functional decline (5). 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 for 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 more than 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.

Acetaminophen may not live up to its popularity

Acetaminophen (e.g., Tylenol) is a popular initial go-to drug for osteoarthritis treatment, but what does research tell us about its effectiveness?

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 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. The exception was an oral Cox-2 inhibitor, celecoxib, which was only marginally better.

What about NSAIDs?

NSAIDs (nonsteroidal anti-inflammatory drugs) help to reduce inflammation, by definition. 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. Interestingly, a newer formulation of diclofenac (Zorvolex) uses submicron particles, which are roughly 20 times smaller than the older version. This allows it to dissolve faster, so it requires a lower 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 (RCT), the newer formulation of diclofenac demonstrated improvement in pain, functionality and quality of life (7). 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 (8).

In a Cochrane meta-analysis review study of 43 RCTs, results showed that chondroitin, with or without glucosamine, reduced the symptom of pain modestly compared to placebo in short-term studies (9). Yet, 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, hopefully meaning fewer side effects.

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 reduce 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) Ann Intern Med. 2015;162:46-54. (7) ACR 2014 Annual Meeting: Abstract 249. (8) Ann Rheum Dis. Online Jan 6, 2014. (9) 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.   

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In a recent study, those who watched at least six hours of TV per day during their lifetime had a decrease in longevity of 4.8 years. Stock photo
Television viewing can lower your physical and mental health

By David Dunaief, M.D.

Dr. David Dunaief

According to the Nielsen Company, Americans spend an average of 10½ hours per day watching programming of some kind, whether on a television, computer or a portable device (1). For our purposes, we’ll call this TV, because most is consumed while sitting, although the average watching modality has shifted considerably.

What impact does all this watching have on our lives? It may be hazardous to your health. I know this seems obvious, but bear with me. The extent of the effect is surprising. According to 2013 Netflix research, binge-watching, or watching more than two or more episodes of a single program in a row, is perceived as providing a refuge from our busy lives. This also has an addictive effect, prompting dopamine surges as we watch. Interestingly, it also can lead to postbinge depression when a show ends and to isolation and lower social interaction while viewing (2).

TV’s detrimental effect extends beyond the psychological, potentially increasing the risk of heart attacks, diabetes, depression, obesity and even decreasing or stunting longevity. My mother was right when she discouraged us from watching television, but I don’t think even she knew the extent of its impact.

Cardiovascular events including heart attacks 

There was a very interesting observational study published in the New England Journal of Medicine that showed watching sporting events increases the risk of heart attacks and other cardiovascular events, such as arrhythmia (irregular heartbeat) and unstable angina (severe chest pain ultimately due to lack of oxygen). The researchers followed Germans who watched the FIFA (soccer) World Cup playoffs in 1996. 

How much did watching increase the risk of cardiovascular events? This depended on what round of the playoffs and how close a game it was. The later the round and the closer the game, the greater the risk of cardiovascular events. Knockout games, which were single elimination, seemed to have the greatest impact on cardiovascular risk. When Germany was knocked out in the semifinals, the finals between France and Italy did not have any cardiovascular effect. 

Overall, men experienced a greater than threefold increase in risk, while women experienced an increased risk that was slightly below twofold. According to the authors, it was not the outcome of the game that mattered most, but the intensity. The study population involved 4,279 German residents in and around the Munich area (3). 

Another study found that, compared to fewer than two hours a day, those who watched four or more hours experienced an increased risk of cardiovascular disease mortality of 80 percent. I know this sounds like a lot of TV, but remember that the average daily American viewing time is significantly over this. This study, called the Australian Diabetes, Obesity, and Lifestyle study (AusDiab) was observational, looking at 8,800 adults over a six-year period (4). 

Impact on life expectancy 

The adage that life tends to pass you by when you watch TV has a literal component. An observational study found that TV may reduce the life expectancy of viewers. In the study, those who watched at least six hours per day during their lifetime had a decrease in longevity of 4.8 years. However, this is not the whole story. What is even more telling is that after the age of 25, for every hour of TV, one might expect to potentially lose 21.8 minutes of life expectancy (5). According to the authors, these results rival those for obesity and sedentary lifestyles.

Diabetes and obesity risk

In the Nurses’ Health Study, for every two hours of television viewing on a daily basis there were increased risks of type 2 diabetes and obesity of 23 and 14 percent, respectively (6). The results show that sitting at work for two hours at a time increased the risk of diabetes and obesity by only 5 and 7 percent, respectively, much less of an effect than TV watching. The authors surmise that we can reduce the incidence of diabetes and obesity by 43 and 30 percent, respectively, by cutting our TV time by 10 hours a week.

Modestly reducing the amount of television is a simple lifestyle modification that can have a tremendous impact on longevity, quality of life and prevention of the top chronic disease. So, step away from your television, tablet or computer and get out in the world.

References:

(1) Nielsen.com (2) nbcnews.com/better/health/what-happens-your-brain-when-you-binge-watch-tv-series-ncna816991. (3) N Engl J Med 2008; 358:475-483. (4) Circulation. 2010 Jan 26;121(3):384-391. (5) Br J Sports Med doi:10.1136/bjsm.2011.085662. (6) JAMA. 2003 Apr 9;289(14):1785-1791.

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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Medication guidelines have changed with recent studies

By David Dunaief, M.D.

Dr. David Dunaief

May is National Stroke Awareness Month, with a focus on raising awareness of stroke risk factors and prevention. This is valuable, since stroke remains one of the top five causes of mortality and morbidity in the United States (1). As a result, we have a wealth of studies that inform us on the roles of medications and lifestyle in managing risk. Of particular importance are changes in medication guidelines that balance the risks and benefits of different stroke prevention regimens.

Medications with beneficial effects

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (2). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (3).

It is important to recognize that high blood pressure and high cholesterol are two of the most significant risk factors for stroke. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Medication combination: negative impact

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (4, 5).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day, an adult dose, it would result in 900,000 major bleeding events per year (6). Do not take an aspirin regimen – even a low-dose aspirin regimen – for stroke prevention without consulting your physician.

Lifestyle modifications

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (7). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (8). 

The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s important role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (9). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose-related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — typically low-dose aspirin — since the risk of a second stroke is high.

References:

(1) cdc.gov. (2) AAN conference: April 2012. (3) Am J Cardiol 2012; 109(9):1308-1314. (4) ISC 2012; Abstract LB 9-4504. (5) www.clinicaltrials.gov NCT00059306. (6) JAMA 2007;297:2018-2024. (7) Stroke. 2011; 42: 3190-3195. (8) J. Nutr. 2011;141(8):1552-1558. (9) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

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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Improving RHR can improve your healthy life span 

By David Dunaief, M.D.

Dr. David Dunaief

What does our 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). A resting heart rate (RHR) above 100 bpm 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.

Resting heart rate’s importance 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

Reducing RHR may be an important component in living a longer, healthier lifestyle. In the Copenhagen Male Study, a prospective 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.

Your resting heart rate can help identify
potential health problems as well as gauge your current heart health.
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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 who were healthy volunteers at least 20 years old.

Heart attacks

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. An interesting follow-up is 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).

Can RHR be too low?

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 and to increase longevity, even for those in the normal range. By monitoring and modifying RHR, we can use it as a tool for primary disease prevention. 

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.

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. 

٭We invite you to check out our weekly Medical Compass MD Health Videos on                                        Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

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Blood pressure is typically highest during the day and lowest at night. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

There are currently about 75 million people with high blood pressure in the U.S. Put another way, one in three adults have this disorder. 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 (1).

Speaking of scary, during nighttime sleeping hours, 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 (2). 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 (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits. These include lifestyle modifications with diet, exercise and potentially supplements.

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 (4). 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. 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.

High blood pressure doesn’t discriminate

One of the most feared complications of hypertension is cardiovascular disease. 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 (5). 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, 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), 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 (6).

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 (7). 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 (8). 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.

Eat your berries

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 (9).

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.

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

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Comparing Paleo and Mediterranean diets

By David Dunaief, M.D.

We have made great strides in the fight against heart disease, yet it remains the number one cause of death in the United States. Why is this? 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 (1). Let’s look at the evidence.

Genetic components

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 (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and 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.

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 this study does not support that, although validating the Paleo-type diet was not its intention. 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 impact on cardiovascular disease risk was published in the New England Journal of Medicine (3). 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 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 a standard 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 (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So who 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.

References:

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) 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.  

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Fiber-rich foods, including whole grains, seeds and legumes, as well as some beverages, such as coffee and wine, contain measurable amounts of lignans. Stock photo
Lignans may reduce diabetes risk

By David Dunaief, M.D.

Dr. David Dunaief

Type 2 diabetes is pervasive throughout the population, regardless of age. Yet, even with its prevalence, many myths persist about managing diabetes. Among these are: Fruit should be limited or avoided; soy has detrimental effects with diabetes; plant fiber provides too many carbohydrates; and bariatric surgery is an alternative to lifestyle changes.

All of these statements are false. Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit was shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at the impacts of different whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

In the Nurses’ Health Study and NHS II, two very large prospective observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (5). The researchers believe the effect is from antioxidant activity.

Soy and kidney function

In diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (6). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

This was a small, but randomized controlled trial over a four-year period with 41 participants. The control group’s diet consisted of 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

Bariatric surgery

In recent years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery involving 16 RCTs and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintain long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery.

References:

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Obes Surg. 2014;24:437-455.

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

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