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Regular exercise helps prevent or manage a wide range of health problems and concerns. Stock photo
The real benefits of exercise

By David Dunaief, M.D.

Dr. David Dunaief

With holiday dinners right around the corner, what would be a better topic than exercise? To quell our guilt about Thanksgiving dinner indiscretions, many of us will resolve to exercise to burn off the calories from this seismic meal and the smaller, calorically dense aftershock meals, whether with a vigorous family football game or with a more modest walk.

Unfortunately, exercise without dietary changes may not actually help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance. Therefore, it may be more important to think about what you are eating than to succumb to the rationalization that you can eat with abandon during the holidays and work it off later.

Don’t give up on exercise just yet, though. There is very good news: Exercise does have beneficial effects on a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.

Let’s look at the evidence.

Weight loss attenuated

The well-known weight-loss paradigm in medicine is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, the results of a study say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women (55) gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. Significant variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise — or, in other words, a moderately intense pace. 

The good news is that the women were in better aerobic shape by the end of the study and that women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study. This was a preliminary study, so no definitive conclusions can be made.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials — the gold standard of studies — results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Weight maintenance

However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Chronic kidney disease

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 14 percent of adults in the United States, according to the Centers for Disease Control and Prevention (7). The U.S. Preventive Services Task Force has indicated that there is insufficient evidence to treat asymptomatic CKD. In fact, the American College of Physicians has said that asymptomatic CKD, which includes stages 3a and 3b, or moderate disease levels, should not be screened for, since the treatment risks outweigh the benefits, and lead to false positive results and unnecessary treatments (8).

However, in a trial, results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3-5 (9). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to nonwalkers.

Walking had an impressive impact; results were based on a dose-response curve. In other words, the more frequently patients walked in the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

Therefore, while it is important to enjoy the holidays, it is food choices, not exercise, that will have the greatest impact on our weight and body composition. However, exercise is extremely beneficial for preventing progression of chronic disorders, such as CKD.

So, by all means, exercise during the holidays, but also focus on more nutrient-dense foods. At a minimum, strike a balance rather than eating purely calorically dense foods. You won’t be able to exercise them away.

References:

(1) uptodate.com. (2) J Strength Cond Res. Online Oct. 28, 2014. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Ann Intern Med. online October 21, 2013. (9) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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
Key lifestyle choices may reduce your risk significantly

By David Dunaief, M.D.

Dr. David Dunaief

Happy “Movember!” The Movember Foundation is in its 11th year of raising awareness and research money for men’s health issues (1). What better time to discuss prostate cancer prevention?

The best way to avoid prostate cancer is through lifestyle modifications, which means learning about both detrimental and beneficial approaches. There are a host of things that may increase your risk and others that may decrease your likelihood of prostate cancer. Your family history does not mean you can’t alter gene expression with the choices you make.

What may increase the risk of prostate cancer? Contributing factors include obesity, animal fat and supplements, such as vitamin E and selenium. Equally as important, factors that may reduce risk include vegetables, especially cruciferous, and tomato sauce or cooked tomatoes.

Vitamin E and selenium

In the SELECT trial, a randomized clinical trial (RCT), a dose of 400 mg of vitamin E actually increased the risk of prostate cancer by 17 percent (2). Though significant, this is not a tremendous clinical effect. It does show that vitamin E should not be used for prevention of prostate cancer. Interestingly, in this study, selenium may have helped to reduce the mortality risk in the selenium plus vitamin E arm, but selenium trended toward a slight increased risk when taken alone. Therefore, I would not recommend that men take selenium or vitamin E for prevention.

Obesity

Obesity showed conflicting results, prompting the study authors to analyze the results further. According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer, however increase risk of aggressive disease (3). Don’t think this means that obesity has protective effects. It’s quite the contrary. The authors attribute the lower incidence of nonaggressive prostate cancer to the possibility that it is more difficult to detect the disease in obese men, since larger prostates make biopsies less effective. What the results tell us is that those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Animal fat, red and processed meats

The risk of developing prostate cancer increases with age. Stock photo

It seems there is a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, a large observational study, those who consumed the highest amount of animal fat had a 63 percent increased risk, compared to those who consumed the least (4).

Here is the kicker: It was not just the percent increase that was important, but the fact that it was an increase in advanced or metastatic prostate cancer. Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you are going to eat red meat, I recommend decreased frequency, like lean meat once every two weeks or once a month.

In another large, prospective (forward-looking) observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (5).

Omega-3s paradox

When we think of omega-3 fatty acids or fish oil, we think “protective” or “beneficial.” However, these may increase the risk of prostate cancer, according to one epidemiological study (6). This study, called the Prostate Cancer Prevention Trial, involving a seven-year follow-up period, showed that docosahexaenoic acid (DHA), a form of omega-3 fatty acid, increased the risk of high-grade disease 2.5-fold. This finding was unexpected. If you choose to eat fish, salmon or sardines in water with no salt are among the best choices.

Lycopene – found in tomato sauce

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown beneficial effects. This may be because, in order to release lycopene, the tomatoes need to be cooked (7). It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit.

In a prospective (forward-looking) study involving 47,365 men who were followed for 12 years, the risk of prostate cancer was reduced by 16 percent (8). The primary source of lycopene in this study was tomato sauce. When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

In the Health Professionals Follow-up Study, the results were similar, with a 21 percent reduction in the risk of prostate cancer (9). Again, tomato sauce was the predominant food responsible for this effect. This was another large observational study with 47,894 participants. Although tomato sauce may be beneficial, many brands are loaded with salt. I recommend to patients that they either make their own sauce or purchase a sauce with no salt, such as one made by Eden Organics.

Vegetable effects

Vegetables, especially cruciferous vegetables, reduce the risk of prostate cancer significantly. In a case-control study (comparing those with and without disease), participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (10). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

When it comes to preventing prostate cancer, lifestyle modification, including making dietary changes, can reduce your risk significantly.

References:

(1) www.movember.com. (2) JAMA. 2011; 306: 1549-1556. (3) Epidemiol Rev. 2007;29:88. (4) J Natl Cancer Inst. 1993;85(19):1571. (5) Am J Epidemiol. 2009;170(9):1165. (6) Am J Epidemiol. 2011 Jun 15;173(12):1429-1439. (7) Exp Biol Med (Maywood). 2002; 227:914-919. (8) J Natl Cancer Inst. 2002;94(5):391. (9) Exp Biol Med (Maywood). 2002; 227:852-859; Int. J. Cancer. 2007;121: 1571–1578. (10) J Natl Cancer Inst. 2000;92(1):61.

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.

Type 2 diabetes is a lifestyle disease — our food choices can either prevent or promote diabetes. Stock photo
Dietary changes are worth the effort

By David Dunaief, M.D.

Dr. David Dunaief

Lifestyle modifications are the most effective way to tackle Type 2 diabetes and its complications. Many in the medical community agree that a combination of diet and exercise is the best approach. However, American Diabetes Association (ADA) guidelines recommend that patients with new onset disease start by combining lifestyle changes with the medication metformin. 

The thinking behind this approach is that too many patients fail on diet alone, and it’s important to reduce glucose (sugar) levels as soon as possible. According to the guidelines’ authors, for most individuals with Type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals, either because of failure to lose weight, weight regain, progressive disease or a combination of factors (1). 

I agree that it is not easy to change your lifestyle, but I also think that, for highly motivated patients, the benefits far outweigh the challenges. Not only can we treat this disease, but we can also prevent its complications, such as heart disease, which are so difficult to treat with medications. 

Type 2 diabetes is caused in large part by poor nutrition. Yes, some people have a higher propensity than others, but if compliant on a diet regimen, you can dramatically reduce your risk. And, while medications may help manage diabetes, they also have varying degrees of undesirable side effects. With lifestyle modifications, though, there are only positive effects.

What type of diet regimen may be used to prevent Type 2 diabetes?

The regimen that has achieved the best results is a plant-based diet rich in vegetables, beans and legumes, nuts and seeds, whole grains and fruits. It also may include animal products with an emphasis on fish. This is a diet that emphasizes good fats, those with lots of omega 3 fatty acids, and is low in saturated fat. The data suggest that antioxidants, such as carotenoids, which can be found in multiple foods in this diet, play an integral role in preventing the disease (2).

A randomized clinical trial, called the PREDIMED study, published in the journal Diabetes Care in January 2011, showed that a Mediterranean-type diet, such as described above, reduced the risk of Type 2 diabetes by 52 percent, when compared to a low-fat diet (3). The incredible part was that these results were seen over a short four years, with negligent weight loss among the trial groups. In other words, the Mediterranean-type diet’s effects extend beyond a change in body mass index. 

An observational study showed that those with the highest compliance with a Mediterranean-type diet had a dramatic risk reduction for developing diabetes of 83 percent (4).

What about treatment?

A study published in the American Journal of Clinical Nutrition showed a low-fat vegan diet had twice the effectiveness in lowering glucose levels, compared to the traditional ADA diet (5). Both groups lost about the same amount of weight. Again, it shows that there is more than just weight loss involved in effective dietary regimens for this disease.

Can we reverse Type 2 diabetes?

In a study I authored in collaboration with Dr. Joel Fuhrman and the University of Pennsylvania Medical Center, results showed that 62 percent of participants who followed a high-nutrient density diet, similar to the Mediterranean-type diet, achieved normal glycemic (sugar) levels (6). Thus, they became nondiabetic. 

Even more impressive, participants were able to reduce the number of overall medications from four to one and discontinue all of their diabetic medications, except for one participant. Of those with high blood pressure, the mean blood pressure was normal at the last data point of the study. There was also significant improvement in the lipid profiles of participants.

These are very positive results for both prevention and treatment of Type 2 diabetes and its complications. The caveat is that it is not easy and takes highly motivated individuals. However, the results are well worth the effort.

References:

(1) Diabetes Care 2018 Jan; 41(Supplement 1): S73-S85. (2) Am J Clin Nutr June 2003 77(6):1434-1441. (3) Diabetes Care 2011(34):14-19. (4) BMJ. 2008 Jun 14;336(7657):1348–1351. (5) Am J Clin Nutr May 2009 89(5):1588S-1596S. (6) Open Jnl Prev Med Aug 2012 2(3):364-371.

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.

Fish oil may help with a range of medical conditions including reducing inflammation. Stock photo
Focus on nutritional options for improving outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Autoimmune diseases affect approximately 23.5 million Americans, most of them women. More than 80 conditions have autoimmunity implications (1). Among the most common are rheumatoid arthritis (RA), lupus, thyroid (hypo and hyper), psoriasis, multiple sclerosis and inflammatory bowel disease. In all autoimmune diseases, the immune system inappropriately attacks organs, cells and tissues of the body, causing chronic inflammation, the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you will  likely acquire others.

Drug treatments

The mainstay of treatment is immunosuppressives. In RA where there is swelling of joints bilaterally, the typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. The disease-modifying anti-rheumatic drugs may slow or stop the progression of joint destruction and increase physical functioning. Remicade reduces C-reactive protein (CRP), a biomarker of inflammation.

However, there are several concerning factors with these drugs. First, the side effect profile is substantial. It includes the risk of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections. It is no surprise that suppressing the immune system would result in increased infection rates. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term randomized clinical trials, but many patients are put on these therapies for 20 or more years. 

So what other methods are available to treat autoimmune diseases? These include medical nutrition therapy using bioactive compounds, which have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression and supplementation.

Nutrition and inflammation

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. While I have not found studies that specifically tested diet in RA treatment, there is a study that looked at the Mediterranean-type diet in 112 older patients where there was a significant decrease in inflammatory markers, including CRP (5).

In another study, participants showed a substantial reduction in CRP with increased flavonoid levels, an antioxidant, from vegetables and apples. Astaxanthin, a carotenoid found in fish, was shown to significantly reduce a host of inflammatory factors in mice, including TNF-alpha (6).

Fish oil

Fish oil may help with a range of medical conditions including reducing inflammation.
Stock photo

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (7). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory, such as NFkB.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (8). When treating patients with autoimmune disease, I typically suggest about 2 grams of EPA plus DHA to help regulate their immune systems. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood thinning effects.

Probiotic supplements

The gut contains approximately 70 percent of your immune system. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (9, 10).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor, TNF-alpha (11). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Fiber

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (12).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (13).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and potentially autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects and thus treat and prevent autoimmune diseases.

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Am J Clin Nutr. 2009 Jan;89(1):248-256. (6) Chem Biol Interact. 2011 May 20. (7) Am J Clin Nutr. 2009 Aug;90(2):415-424. (8) Drugs. 2003;63(9):845-853. (9) Gut. 2003 Jul;52(7):975-980. (10) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (11) Gut. 2002;51(5):659. (12) Arch Intern Med. 2007;167(5):502-506. (13) Nutr Metab (Lond). 2010 May 13;7:42.

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.

Recent research focuses on modest lifestyle changes

By David Dunaief, M.D.

Dr. David Dunaief

Parkinson’s disease has burst into the public consciousness in recent years. It is a neurodegenerative (the breakdown of brain neurons) disease with the resultant effect of a movement disorder. 

Most notably, patients with the disease suffer from a collection of symptoms known by the mnemonic TRAP: tremors while resting, rigidity, akinesia/bradykinesia (inability/difficulty to move or slow movements) and postural instability or balance issues. It can also result in a masked face, one that has become expressionless, and potentially dementia, depending on the subtype. There are several different subtypes; the diffuse/malignant phenotype has the highest propensity toward cognitive decline (1).

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (2). Why not add back dopamine? Actually, this is the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

Risk factors may include head trauma, reduced vitamin D, milk intake, well water, being overweight, high levels of dietary iron and migraine with aura in middle age.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also with lifestyle modifications. Lifestyle factors include iron, vitamin D and CoQ10. The research, unfortunately, is not conclusive, though it is intriguing.

Let’s look at the research.

The role of iron

This heavy metal is potentially harmful for neurodegenerative diseases such as Alzheimer’s disease, macular degeneration, multiple sclerosis and, yes, Parkinson’s disease. The problem is that this heavy metal can cause oxidative damage.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (3). This drug was mostly well tolerated.

The chelator reduced the risk of disease progression significantly on the Unified Parkinson Disease Rating Scale (UPDRS). 

Participants who were treated sooner had lower levels of iron compared to a group that used the chelator six months later. A specialized MRI was used to measure levels of iron in the brain. This trial was 12 months in duration.

The iron chelator does not affect, nor should it affect, systemic levels of iron, only those in the brain specifically focused on the substantia nigra region. The chelator may work by preventing degradation of the dopamine-containing neurons. It also may be recommended to consume foods that contain less iron.

CoQ10

When we typically think of using CoQ10, a coenzyme found in over-the-counter supplements, it is to compensate for depletion from statin drugs or due to heart failure. Doses range from 100 to 300 mg. However, there is evidence that CoQ10 may be beneficial in Parkinson’s at much higher doses. 

In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to the placebo group (4). Other doses of 300 and 600 mg showed trends toward benefit but were not significant. This was a 16-month trial in a small population of 80 patients. Though the results for other CoQ10 studies have been mixed, these results are encouraging. Plus, CoQ10 was well tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with Parkinson’s disease.

Vitamin D: Good or bad?

In a prospective (forward-looking) study, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (5). This is quite impressive, especially since the highest quartile patients had vitamin D levels that were what we would qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less. There were over 3,000 patients involved in this study with an age range of 50 to 79.

When we think of vitamin D, we wonder whether it is the chicken or the egg. Let me explain. Many times we are deficient in vitamin D and have a disease, but replacing the vitamin does nothing to help the disease. Well, in this case it does. It turns out that vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In an RCT, results showed that 1,200 IU of vitamin D taken daily may have reduced the progression of Parkinson’s disease significantly on the UPDRS compared to a placebo over a 12-month duration (6). Also, this amount of vitamin D increased the blood levels by two times from 22.5 to 41.7 ng/ml. There were 121 patients involved in this study with a mean age of 72.

So, what have we learned? Though medication with dopamine agonists is the gold standard for the treatment of Parkinson’s disease, lifestyle modifications can have a significant impact on both prevention and treatment of this disease. Each lifestyle change in isolation may have modest effects, but cumulatively they might pack quite a wallop. The most exciting part is that lifestyle modifications have the potential to slow the progression of the disease and thus have a protective effect. Iron chelators specific to the brain may also be very important in disease modification. This also brings vitamin D back into the fold as a potential disease modifier.

References:

(1) JAMA Neurol. 2015;72:863-873. (2) uptodate.com. (3) Antioxid Redox Signal. 2014;10;21(2):195-210. (4) Arch Neurol. 2002;59(10):1541-1550. (5) Arch Neurol. 2010;67(7):808-811. (6) Am J Clin Nutr. 2013;97(5):1004-1013.

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.

In recent studies, the Mediterranean-type diet decreased mortality significantly. Stock photo
Many Americans are malnourished

By David Dunaief, M.D.

Dr. David Dunaief

It may come as a surprise, but most of us are malnourished. How could that be, when approximately 70 percent of the U.S. population is overweight or obese? When we think of malnourishment, developing countries come to mind. However, malnourishment is not directly correlated with hunger; it is common at all levels of the socioeconomic scale. The definition of malnourished is insufficient nutrition, which in the U.S. results from low levels of much needed nutrients.

Over the last 30 years, the pace of increase in life expectancy has slowed substantially. In fact, a New England Journal of Medicine article noted that life expectancy may actually decline in the near future (1). 

According to the American Medical Association, almost half of Americans have at least one chronic disease, with 13 percent having more than three (2). The projection is that 157 million Americans will have more than one chronic disease by 2020. Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients, according to the Centers for Disease Control and Prevention (CDC). 

I regularly test patients’ carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. They are measurable and give the practitioner a sense of whether the patient may lack potentially disease-fighting nutrients. Testing is often covered if the patient is diagnosed with moderate malnutrition. Because the standard American diet is very low in nutrients, classifying a patient with moderate malnutrition can be appropriate. A high nutrient intake approach can rectify the situation and increase, among others, carotenoid levels.

What is a high nutrient intake and why is it so important?

A high nutrient intake is an approach that focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals — plant nutrients. Micronutrients are bioactive compounds found mostly in foods and some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum is greater than the parts. Diets that are plant rich raise the levels of micronutrients considerably in patients.

Let’s look at some examples.

A study showed olive oil reduces the risk of stroke by 41 percent (3). The authors attribute this effect at least partially to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. There are 120 calories per tablespoon of olive oil, all of them fat. If you eat too much, even of good fat, it defeats the purpose. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s. 

In a case-control (compare those with and without disease) study, high intake of antioxidants from food is associated with a significant decrease in the risk of early age-related macular degeneration (AMD), even when participants had a genetic predisposition for the disease (4). AMD is the leading cause of blindness in those 55 years or older. There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA, substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

What can we do to improve life expectancy?

In the Greek EPIC trial, a large prospective (forward-looking) cohort study, the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). 

The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

Though many Americans are malnourished, nutrients that are effective and available can alter this predicament or epidemic. Hopefully, with a focus on a high nutrient intake, we can re-ignite the pace of increased life expectancy and improve quality of life for the foreseeable future.

References:

(1) N Engl J Med 2005; 352:1138-1145. (2) www.ama-assn.org. (3) Neurology June 15, 2011. (4) Arch Ophthalmol. 2011;129(6):758-766. (5) BMJ. 2009;338:b2337.

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.

There are serious side effects of NSAIDs and Tylenol

Dr. David Dunaief

Most of us keep a few key items in our medicine cabinets. In addition to aspirin, among these are usually NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophen (Tylenol). We often use them for relief of pain, fever or inflammation. Familiar NSAIDs include ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). It is estimated that more than 17 million people use NSAIDs on a daily basis. According to a poll of these regular users of over-the-counter (OTC) NSAIDs, a substantial number — 60 percent — were unaware of their dangerous side effects (1).

Acetaminophen is used frequently, as well. On a weekly basis, one quarter of Americans take it. 

We think of these drugs as relatively benign. In fact, I find that unless I specifically ask about their use, most patients don’t include them on a list of their medications on a patient registration form. 

NSAIDs: The statistics

Unfortunately, NSAIDs, according to the Centers for Disease Control and Prevention, are responsible for 7,600 deaths annually and 10 times that number in hospitalizations (2). These are not medications that should be taken lightly. NSAIDs increase the risk of several maladies, including erectile dysfunction, heart attacks, gastrointestinal bleeds, exacerbation of diverticular disease and chronic arrhythmias (abnormal heartbeats). In some instances, the cardiovascular effects can be fatal. 

NSAIDs: Studies demonstrating adverse side effects

In a case control (epidemiologic, retrospective) study using the UK Primary Care Database, chronic users of NSAIDs have a significantly increased risk of a serious arrhythmia (abnormal heartbeat) called atrial fibrillation (3). Patients were between 40 and 89 years of age. 

Interestingly, chronic users were defined as patients who took NSAIDs for more than 30 days. Those patients who used NSAIDs more than 30 days had a 57 percent increased risk of atrial fibrillation. A Danish study reinforces these results after the first month of use (4). This is not very long to have such a substantial risk. For patients who used NSAIDs longer than one year, the risk increased to 80 percent. Caution should be used when prescribing NSAIDs or when taking them OTC. Atrial fibrillation is not an easy disease to treat.

NSAIDs also increase the risk of mortality in chronic users. Older patients who have heart disease or hypertension (high blood pressure) and are chronic NSAIDs users are at increased risk of death, according to an observational study (5). Compared to those who never or infrequently used them over about 2.5 years, chronic users had a greater than twofold increase in death due to cardiovascular causes. High blood pressure was not a factor, since the chronic users actually had lower blood pressure. Yet I have seen with my patients that NSAIDs can increase blood pressure. 

Is acetaminophen the answer?

Acetaminophen does not cause gastrointestinal bleeds, arrhythmias and deaths due to cardiovascular events that NSAIDs can. However, the Food & Drug Administration announced in 2011 that acetaminophen should not exceed 325 mg every four to six hours when used as a prescription combination pain reliever (6). The goal is to reduce and avoid severe injury to the liver, which can potentially cause liver failure. 

There is an intriguing paradox with acetaminophen: Hospitals typically dispense regular-strength 325-mg doses of the drug, whereas OTC doses frequently are found in extra-strength 500-mg tablets, and often the suggested dose is two tablets, or 1 gram. Patients should not take more than 4 grams a day to lower their risk of liver damage. The 4-gram amount sounds like a significant quantity, but it translates into two pills of extra-strength Tylenol every six hours.

I have patients who have taken three pills at one time thinking that, since it is OTC, exceeding the dose is okay. Unfortunately, this is not true. 

The FDA’s recommendations for limiting the dose result from a conglomeration of data. For instance, one study that showed acute liver failure was due primarily to unintentional overdoses of acetaminophen (7). Accidental overdosing is more likely to occur when taking acetaminophen at the same time as a combination sinus, cough or cold remedy that also contains acetaminophen. Over-the-counter cold medications can contain acetaminophen. 

In order to be aware of potentially adverse events, you have to be your own best advocate and read labels. Remember to tell your physician if you are taking OTC medications. If you are a chronic user of NSAIDs because of underlying inflammation, you may find an anti-inflammatory diet, which is usually plant-based, is an effective alternative.

References: 

(1) J Rheumatol. 2005;32;2218-2224. (2) Annals of Internal Medicine, 1997;127:429-438. (3) Arch Intern Med. 2010;170(16):1450-1455. (4) BMJ 2011;343:d3450. (5) Am J Med. 2011 Jul;124(7):614-620. (6) FDA.gov. (7) Am J Gastroenterol. 2007;102:2459-2463. 

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 new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

The best protection against kidney stones is a combination of low sodium and high fluid intake. Stock photo
Calcium from supplements may increase risk of kidney stone formation

By David Dunaief, M.D.

Dr. David Dunaief

Kidney stones are relatively common, occurring more often in men than women (1). I have seen many patients who have a history of forming these stones. Unfortunately, once a patient forms one stone, the incidence of another increases significantly over time. However, there are several ways to reduce your risk.

Kidney stones, or nephrolithiasis, can be asymptomatic (no symptoms at all) or may present with the classic symptoms of blood in the urine and colicky pain. Pain can be intermittent or constant, ranging from dull to extremely painful, described by some as being worse than giving birth or being shot or burned. 

The pain may radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (2). Stones are usually diagnosed through clinical suspicion and abdominal X-rays and/or noncontrast CT scans.

Unfortunately, the first line treatment for passing kidney stones — at least small ones — involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are <4 mm pass spontaneously. Location is an important factor as well, with stones closest to the opening of the urethra more likely to pass (3).

Prevention is the way to go

The good news is there are lifestyle changes that can reduce the risk of kidney stones. First, it is very important to stay hydrated, drinking plenty of fluids, especially if you have a history of stone formation (4).

One of the easiest methods is to significantly reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones, with calcium oxalate being the dominant one, occurring approximately 80 percent of the time (5). Calcium supplements increase the risk of kidney stones. When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (6). 

According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (7). It did not matter whether participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, calcium from dietary sources actually has the opposite effect, decreasing risk. In the same study, those participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest group. Calcium intake should not be too low, for that also increases kidney stone risk. However, the source of calcium is a key to preventing kidney stones. 

Another modifiable risk factor is sodium. It’s important to reduce sodium for many reasons, and this provides one more. Again, in the Nurses’ Health Study, participants who consumed 4.5 g sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 g per day (7). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones. 

Animal protein also seems to play a role. In a five-year, randomized clinical trial, men who consumed small amounts of animal protein, approximately two ounces per day, and lower sodium were 51 percent less likely to experience a kidney stone than those who consumed low amounts of calcium (8). These were men who had a history of stone formation. The reason that animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that its higher sulfur content produces more acid, which is neutralized by release of calcium from the bone (9).

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study (a certain population during a specific period) with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (10). Amazingly, it did not matter if the patients were treated for high blood pressure; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not the symptoms.

The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more changes that you implement, the lower your risk of stones.

References: 

(1) Kidney Int. 1979;16(5):624. (2) emedicine Jan 1, 2008. (3) J Urol. 2006;175(2):575. (4) J Urol. 1996;155(3):839. (5) N Engl J Med. 2004;350(7):684. (6) Kidney Int 2003;63:1817–1823. (7) Ann Intern Med. 1997;126(7):497-504. (8) N Engl J Med. 2002 Jan 10;346(2):77-84. (9) J Clin Endocrinol Metab. 1988;66(1):140. (10) BMJ. 1990;300(6734):1234. 

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 new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

One can maintain regular bowel movement and lessen the risk of inflamed hemorrhoids by including more fiber in his or her diet, about 30 g per day. Stock photo
Most Americans don’t get enough fiber

By David Dunaief, M.D.

Dr. David Dunaief

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and child birth. For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms — and often say we “have hemorrhoids” — when we really mean our hemorrhoids are causing us pain. 

When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually bleed, especially during a bowel movement, which may scare most of us. Fortunately, hemorrhoids are not a harbinger of more serious disease. 

Treating external hemorrhoids

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Thus, they can be self-treated and do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet and supplementation (1). However, sometimes there is thrombosis (clotting) of external hemorrhoids, in which case they may become more painful, requiring medical treatment.

Treating internal hemorrhoids

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they are usually above the point of sensation in the colon, called the dentate line. If the hemorrhoids prolapse below this, there may be pain and discomfort, as well. Prolapse is when hemorrhoids fall out of place, due to weakening of the muscles and ligaments in the colon. 

The first step for treating internal hemorrhoids is to add fiber through diet and supplementation. Study after study shows significant benefit. For instance, in a meta-analysis by the Cochrane Systems Data Review 2005, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, the daily incidence of bleeding was reduced dramatically (3).

There are several minimally invasive options, including anal banding, sclerotherapy and coagulation. The most effective of these is anal banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where two rubber bands are place at the neck of each hemorrhoid. To avoid complications from constipation, patients should also take fiber supplementation. 

Side effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgery) would be the next option.

How to prevent hemorrhoids

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing the risk of inflammation. Though you may want private time to read, the bathroom is not the library. As soon as you have finished moving your bowels, it is important to get off the toilet.

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining. Thus, you should try to increase the amount of fiber in your diet, before adding supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes have significant amounts of fiber. Grains, beans and nuts have among the highest levels of fiber. For instance, one cup of black beans has 12 g of fiber. 

Americans, on average, consume 16 g per day of fiber (5). For the average female or male between ages 31 and 50, the USDA recommends 25 and 30 g per day, respectively (6). I would recommend at least 40 g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65 g per day. You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned — side effects are potentially gas and bloating for the first week or two.

Get plenty of fluids. It helps to soften the stool and prevent constipation. Exercise also helps to prevent constipation. It is important not to hold in a bowel movement; go when the urge is there or else the stool can become hard, causing straining, constipation and more time on the toilet. 

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should see your physician to make sure it is not due to a malignancy or other cause, such as inflammatory bowel disease. The message throughout this article is that Americans need to get more fiber, which is beneficial for inflamed hemorrhoid prevention and treatment.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-456. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-1507. (4) Dis Colon Rectum 2004 Aug;47(8):1364-1370. (5) emedicine.com 2010. (6) health.gov. 

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 new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.

Symptoms of diverticular disease include lower abdominal pain and feeling bloated.
Fiber intake can affect results

By David Dunaief, M.D.

Dr. David Dunaief

Many patients say they have been diagnosed with diverticulitis, but this is a misnomer. Diverticulitis is actually a sequelae, or consequence, of diverticular disease. Diverticular disease is one of the most common maladies that affects us as we age. For instance, 10 percent of 40-year-olds are affected and, for those over the age of 60, more than 50 percent are affected (1).

The good news is that it is potentially preventable through modest lifestyle changes. My goal in writing this article is twofold: to explain simple ways to reduce your risk, while also debunking a myth that is pervasive — that fiber, or more specifically nuts and seeds, exacerbates the disease.

What is diverticular disease? It is a weakening of the lumen, or wall of the colon, resulting in the formation of pouches or out-pocketing referred to as diverticula. The cause of diverticula may be attributable to pressure from constipation. Its mildest form, diverticulosis may be asymptomatic. 

Symptoms of diverticular disease may include fever and abdominal pain, predominantly in the left lower quadrant in Western countries, or the right lower quadrant in Asian countries. It may need to be treated with antibiotics.

Diverticulitis affects 10 to 25 percent of those with diverticulosis. Diverticulitis is inflammation and infection, which may lead to a perforation of the bowel wall. If a rupture occurs, emergency surgery may be required.

Unfortunately, the incidence of diverticulitis is growing. Between 1998 and 2005, hospital admissions for acute diverticulitis increased 26 percent overall with a 73 percent increase in those between the ages of 18 and 44 (2).

Fiber, or more specifically nuts and seeds, does not exacerbate the disease.

How do you prevent diverticular disease and its complications? There are a number of modifiable risk factors, including fiber intake, weight and physical activity.

In terms of fiber, there was a prospective (forward-looking) study published online in the British Medical Journal that extolled the value of fiber in reducing the risk of diverticular disease (3). This was part of the EPIC trial, involving over 47,000 people living in Scotland and England. The study showed a 31 percent reduction in risk in those who were vegetarian. 

But more intriguing, participants who had the highest fiber intake saw a 41 percent reduction in diverticular disease. Those participants in the highest fiber group consumed >25.5 grams per day for women and >26.1 grams per day for men, whereas those in the lowest group consumed less than 14 grams per day. Though the difference in fiber between the two groups was small, the reduction in risk was substantial. 

Another study, which analyzed data from the Million Women Study, a large-scale, population-based prospective UK study of middle-aged women, confirmed the correlation between fiber intake and diverticular disease, and further analyzed the impact of different sources of fiber (4). The authors’ findings were that reduction in the risk of diverticular disease was greatest with high intake of cereal and fruit fiber.

Most Americans get <14 grams of fiber per day. The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 grams for women and 38.5 grams for men. Interestingly, their recommendations are lower for those who are over 50 years old.

Can you imagine what the effect is when people get at least 40 grams of fiber per day? This is what I recommend for my patients. Some foods that contain the most fiber include nuts, seeds, beans and legumes. In a study in 2009, specifically those men who consumed the most nuts and popcorn saw a protective effect from diverticulitis (5).

Obesity plays a role, as well. In the large prospective male health professionals study, body mass index plays a significant role, as did waist circumference (6). Those who were obese (BMI >30 kg/m²) had a 78 percent increased risk of diverticulitis and a greater than threefold increased risk of a diverticular bleed compared to those who had a BMI in the normal range of <21 kg/m². For those whose waist circumference was in the highest group, they had a 56 percent increase risk of diverticulitis and a 96 percent increase risk of diverticular bleed. Thus, obesity puts patients at a much higher risk of the complications of diverticulosis.

Physical activity is also important for reducing the risk of diverticular disease, although the exact mechanism is not yet understood. Regardless, the results are impressive. In a large prospective study, those with the greatest amount of exercise were 37 percent less likely to have diverticular disease compared to those with the least amount (7). Jogging and running seemed to have the most benefit. When the authors combined exercise with fiber intake, there was a dramatic 256 percent reduction in risk of this disease. 

Thus, the prevention of diverticular disease is one based mostly on lifestyle modifications through diet and exercise.

References:

(1) Journal of Clinical Gastroenterology. 2006;40:S108–S111. (2) Ann Surg. 2009;249(2):210. (3) BMJ. 2011; 343: d4131. (4) Gut. 2014 Sep; 63(9): 1450–1456. (5) AMA 2008; 300: 907-914. (6) Gastroenterology. 2009;136(1):115. (7) Gut. 1995;36(2):276.  

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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