Health

Studies have shown that eating fresh fruit and cinnamon may be beneficial to diabetics. Stock photo
Fresh fruit and cinnamon may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

What causes Type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 12.2 percent of the U.S. population aged 18 or older has Type 2 diabetes, and about 9.4 percent when factoring all ages (1).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars, because form is important. Sugar and fruit are not the same with respect to their effects on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of Type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage, however, we are talking about the overall prevalence, which is around 9.4 percent in the U.S., as we noted above.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12-ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to municipal efforts to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

Effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — Type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a body mass index of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels.

It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have Type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat Type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However, it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with articles I’ve written on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make lifestyle changes. So America, take an active role.

References:

(1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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.      

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Speedy diagnosis and treatment improves outcomes

By David Dunaief, M.D.

Dr. David Dunaief

TIA (transient ischemic attack) is sometimes referred to as a “mini-stroke.” This is a disservice since it makes a TIA sound like something that should be taken lightly. Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot across the bow that needs to be taken very seriously on its own. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (1). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. I have helped manage patients with symptoms as understated as the onset of double vision. Other symptoms may include facial or limb weakness on one side, slurred speech or problems comprehending others, dizziness or difficulty balancing or blindness in one or both eyes (2). TIA incidence increases with age (3).

What is a TIA?

It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia (low blood flow in the back of the eye) without evidence of acute infarction (tissue death) (4). In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, creating difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Though they are temporary, TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death. Despite the seriousness of TIAs, patients or caregivers often delay receiving treatment.

Stroke risk

A TIA is a stroke that lasts only a few minutes.
Stock photo

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (5). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (6). Even worse, over the long term, the probability that a patient will experience a stroke reaches approximately 30 percent, one in three, after five years (7).

The EXPRESS study, a population-based study that considered the effect of urgent treatment of TIA and minor stroke on recurrent stroke, evaluated 1,287 patients, comparing their initial treatment times after experiencing a TIA or minor stroke and their subsequent outcomes (8).

The Phase 1 cohort was assessed within a median of three days of symptoms and received a first prescription within 20 days. In Phase 2, median delays for assessment and first prescription were less than one day. All patients were followed for two years after treatment. Phase 2 patients had significantly improved outcomes over the Phase 1 patients. Ninety-day stroke risk was reduced from 10 to 2 percent, an 80 percent improvement.

The study’s authors advocate for the creation of TIA clinics that are equipped to diagnose and treat TIA patients to increase the likelihood of early evaluation and treatment and decrease the likelihood of a stroke within 90 days. The moral of the story is: Treat a TIA as a stroke should be treated, the faster the diagnosis and treatment, the lower the likelihood of sequalae, or complications.

Predicting the risk of stroke

Both DWI (diffusion-weighted imaging) and ABCD2 are potentially valuable predictors of stroke after TIA. The ABCD2 is a clinical tool used by physicians. ABCD2 stands for Age, Blood pressure, Clinical features and Diabetes, and it uses a scoring system from 0 to 7 to predict the risk of a stroke within the first two days of a TIA (9).

Heart attack

In one epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (10). These were patients without known heart disease. Interestingly, the risk of heart attacks was much higher in those over 60 years of age and continued for years after the event. Just because you may not have had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack.

Mortality

TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years and by 20 percent after nine years, especially in those over age 65 (11). The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (12). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (13). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include a Mediterranean and DASH diet combination. Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

If you or someone you know has TIA symptoms, the patient needs to see a neurologist and a primary care physician and/or a cardiologist immediately for assessment and treatment to reduce risk of stroke and other long-term effects.

References:

(1) Stroke. Apr 2005;36(4):720-723; Neurology. May 13 2003;60(9):1429-1434. (2) mayoclinic.org. (3) Stroke. Apr 2005;36(4):720-723. (4) N Engl J Med. Nov 21 2002;347(21):1713-1716. (5) Neurology. 2011 Sept 27; 77:1222. (6) Lancet Neurol. Dec 2007;6(12):1063-1072. (7) Albers et al., 1999. (8) Stroke. 2008;39:2400-2401. (9) Lancet. 2007;9558;398:283-292. (10) Stroke. 2011; 42:935-940. (11) Stroke. 2012 Jan;43(1):79-85. (12) Stroke. 2011 Jul;42(7):1857-1861. (13) JAMA. 2005 Mar 23;293(12):1435.

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.    

Peter Scully, Suffolk County deputy county executive and water czar, responds to questions from  TBR News Media’s editorial staff:

1. You’ve been called Suffolk County’s water czar. Why does Suffolk County need a water czar?

The need for the county to have a high-level point person to advance the water quality agenda of County Executive Steve Bellone [D] is a result of two factors: The high priority that the county executive has placed on water quality issues, and the tremendous progress his administration has made over the past seven years in building a solid foundation to reverse decades of nitrogen pollution that has resulted primarily from the lack of sewers in Suffolk County and reliance on cesspools and septic systems that discharge untreated wastewater into the environment. The county executive succeeded in landing $390 million in post-Hurricane Sandy resiliency funding to eliminate 5,000 cesspools along river corridors on the South Shore by connecting parcels to sewers, and the county’s success in creating a grant program to make it affordable for homeowners to replace cesspools and septic systems with new nitrogen-reducing septic systems in areas where sewers are not a cost-effective solution, prompted the state to award Suffolk County $10 million to expand the county’s own Septic Improvement Program. These are the largest investments in water quality Suffolk has seen in 50 years, and the county executive saw the need to appoint a high-level quarterback to oversee the implementation of these programs.

 

2. Which groundwater contaminants are the highest priorities for Suffolk County? 

In 2014, the county executive declared nitrogen to be water quality public enemy No. 1. The nitrogen in groundwater is ultimately discharged into our bays, and about 70 percent of this nitrogen comes from on-site wastewater disposal (septic) systems. Excess nutrients have created crisis conditions, causing harmful algal blooms, contributing to fish kills and depleting dissolved oxygen necessary for health aquatic life. They have also made it impossible to restore our once nationally significant hard clam and bay scallop fisheries, have devastated submerged aquatic vegetation and weakened coastal resiliency through reduction of wetlands. Nitrogen also adversely impacts quality of drinking water, especially in areas with private wells, although public water supply wells consistently meet drinking water standards for nitrogen.

Other major contaminants of concern include volatile organic compounds, known as VOCs. For example, there is perchloroethlyene, historically from dry cleaners; and petroleum constituents — most recently MTBE, a gasoline additive — from fuel storage and transfer facilities.

Then there are pesticides. Active ingredients such as chlordane, aldicarb and dacthal have been banned, but some legacy contamination concerns exist, especially for private wells. Some currently registered pesticides are appearing in water supplies at low levels, including simazine/atrazine, imidacloprid and metalaxyl.

Emerging contaminants include PFAS, historically used in firefighting foams, water repellents, nonstick cookware; and 1,4-dioxane, an industrial solvent stabilizer also present at low levels in some consumer products. 

 

3. Are the chemicals coming from residential or industrial sites?

Contamination can emanate from a variety of sites, including commercial, industrial and residential properties. Many of the best-known cleanup sites are dealing with legacy impacts from past industrial activity. Examples include Grumman in Bethpage, Lawrence Aviation in Port Jefferson Station, Brookhaven National Laboratory in Upton and the Naval Weapons Industrial Reserve Plant in Calverton. There have been hundreds of Superfund sites on Long Island. Fortunately, most are legacy sites and new Superfund sites are relatively rare.

More recently, the use of firefighting foam has resulted in Superfund designations at the Suffolk County Firematics site in Yaphank, Francis S. Gabreski Air National Guard Base in Westhampton, and East Hampton Airport. The foam was used properly at the time of discharge, but it was not known that PFAS would leach and contaminate groundwater.

The county’s 2015 Comprehensive Water Resources Management Plan found that some chemicals, such as VOCs, continue to increase in frequency of detection and concentration. While some of this is attributable to legacy industrial plumes, experts believe that residential and small commercial sites are partially responsible for contamination. This is partly because any substances that are dumped into a toilet or drain will reach the environment, and because solvents move readily through our sandy aquifer. Septic waste is, of course a major of contamination. Residential properties can be also responsible for other pollution, such as nitrogen from fertilizers and pesticides.

4. Which industries currently generate the most groundwater pollution in Suffolk County? 

The county’s Department of Health Services Division of Environmental Quality staff advise that, historically, the major contributors to groundwater pollution in the county were dry cleaners, and fuel storage and transfer facilities. However, current dry cleaning practices have minimized any possible groundwater discharges, and modern fuel facilities are engineered to more stringent code requirements that have substantially eliminated catastrophic releases. Low-level discharges are still a concern, and are the subject of the county’s VOC action plan to increase inspections and optimize regulatory compliance.

There are thousands of commercial and industrial facilities, most of which have the potential to pollute — for example, with solvent cleaners. Best management practices and industrial compliance inspections are key to minimizing and eliminating further contamination.

 

5. The word “ban” is often a dirty word in politics, but do you see benefits to banning certain products, and/or practices, for the sake of protecting the county’s drinking water supply? (The bans on DDT, lead in gasoline and HFCS, for example, were very effective at addressing environmental and human health concerns.) 

Policymakers have not hesitated to ban the use of certain substances — DDT, lead in gasoline, chlordane, MTBE — in the face of evidence that the risks associated with the continued introduction of a chemical into the environment outweigh the benefits from a public health or environmental standpoint. Based on health concerns, I expect that there will be active discussion in the years ahead about the merits of restricting the use of products that introduce emerging contaminants like 1,4-dioxane and PFCs into the environment.

 

6. If people had more heightened awareness, could we slow or even eliminate specific contaminants? As consumers, can people do more to protect groundwater? 

There is no question that heightened awareness about ways in which everyday human activities impact the environment leads people to change their behaviors in ways that can reduce the release of contaminants into the environment. A good example is the county’s Septic Improvement Program, which provides grants and low interest loans for homeowners who choose to voluntarily replace their cesspools or septic systems with new nitrogen-reducing technology. More than 1,000 homeowners have applied for grants under the program, which set a record in October with more 100 applications received.

If a home is not connected to sewers, a homeowner can replace their cesspool or septic system with an innovative/alternative on-site wastewater treatment system. Suffolk County, New York State and several East End towns are offering grants which can make it possible for homeowners to make this positive change with no significant out-of-pocket expense. Consumers can choose to not flush bleaches or toxic/hazardous materials down the drain or into their toilets. Consumers can also take care to deliver any potentially toxic or hazardous household chemicals to approved Stop Throwing Out Pollutants program sites. Homeowners can choose not to use fertilizers or pesticides, or to opt for an organic, slow-release fertilizer at lowest label setting rates.

 

7. Can you offer examples of products to avoid or practices to adopt that would better protect the drinking water supply? 

Consumers can choose to not flush bleaches or household hazardous materials down the drain or into their toilets. Consumers can also take care to deliver any potentially toxic or hazardous household chemicals to approved STOP program sites. Homeowners can choose not to use fertilizers or pesticides, or to opt for an organic, slow release fertilizer at lowest label setting rates.

 

8. Aside from banning products or chemicals, and raising awareness, how do you address the issue?

Promoting the use of less impactful alternatives to products which have been shown to have a significant and/or unanticipated impact on public health or the environment, on a voluntary basis, is a less contentious approach than banning a substance or placing restrictions on its use through a legislative or rulemaking process. Such an approach should only be taken with the understanding that its success, value and significance will depend in large part on public awareness and education.

 

9. What about product labeling, similar to the U.S. Office of the Surgeon General warnings about cigarettes, or carcinogens in California, etc.? Can the county require products sold to include a groundwater contamination warning?

The question of whether the county Legislature has authority to implement labeling requirements could be better addressed by an attorney.

 

10. People, including some elected officials and people running for public office, sometimes say that sewage treatment plants remove all contaminants from wastewater. Can you set the record straight? What chemicals, including radioactive chemicals, are and are not removed from wastewater via sewage treatment?

Tertiary wastewater treatment plants are designed primarily to remove nitrogen, in addition to biodegradable organic matter. However, wastewater treatment is also effective at removing many volatile organic compounds. Some substances, such as 1,4-dioxane, are resistant to treatment and require advanced processes for removal. Evidence shows that the use of horizontal leaching structures instead of conventional drainage rings may facilitate removal of many pharmaceuticals and personal care products, known as PPCPs. Advanced treatment technologies, such as membrane bioreactors, are also being tested for efficacy of removal of PPCPs.

Staff advise that the mere presence of chemicals in wastewater in trace amounts does not necessarily indicate the existence of a public health risk. All wastewater treatment must treat chemicals to stringent federal and state standards. In some cases, such as for emerging contaminants, specific standards do not exist. In those cases, the unspecified organic contaminant requirement of 50 parts per billion is commonly applied.

 

11. Can you provide an example of a place where residential and industrial groundwater contamination concerns were reversed or adequately addressed?

There are numerous examples, mostly under the jurisdiction of U.S. Environmental Protection Agency or NYS Department of Environmental Conservation, in which groundwater concerns have been addressed through treatment to remove contaminants. Because health and safety are always the most important issues, the first priority is typically to make sure that people who live near an impacted site have a safe supply of drinking water. In areas served by public water suppliers — Suffolk County Water Authority or a local water district — this is not usually an issue, since public water suppliers are highly regulated and are required to test water supply wells regularly. In areas where people are not connected to a public water system, and rely instead on private wells, the Suffolk County Department of Health Services will work with the water supplier to identify properties that are not connected to a public water system and then contact homeowners to urge them to have their water tested at no charge to make sure that it is safe for consumption. 

Over the past several years, Suffolk County, New York State and the Suffolk County Water Authority have worked together to connect hundreds of homes that had relied on private wells to the public water system, to make sure people have access to safe drinking water.

 

12. Are you hopeful about addressing the issues? 

I am hopeful and optimistic about the success of efforts to reverse the ongoing degradation of water quality that has resulted from reliance on cesspools and septic systems. For the first time in Long Island’s history, environmentalists, business leaders, scientists, organized labor and the building trades all agree that the long-term threat that has resulted from the lack of sewers to both the environment and economy is so great that a long-term plan to address the need for active wastewater treatment is not an option, but a necessity. Experience shows that public awareness can be a significant factor in driving public policy.

Eat the colors of the rainbow to reduce the risk of dementia. Stock photo
Intensive lifestyle changes may grow protective telomeres

By David Dunaief, M.D.

Dr. David Dunaief

Dementia may be diagnosed when someone experiences loss of memory plus loss of another faculty, such as executive functioning (decision-making) or language abilities (speaking, writing or reading). The latter is known as aphasia. Alzheimer’s disease is responsible for approximately 60 to 80 percent of dementia cases (1).

Unfortunately, there are no definitive studies that show reversal or a cure for Alzheimer’s disease. This is why prevention is central to Alzheimer’s — and dementia in general.

In terms of dementia, there is good news and some disappointing news.

We will start with the good news. Though chronological age is a risk factor that cannot be changed, biological age may be adjustable. There are studies that suggest we may be able to prevent dementia through the use of both lifestyle modifications and medications.

Telomeres’ length and biological age

Biological age may be different from chronologic age, depending on a host of environmental factors that include diet, exercise and smoking. There are substances called telomeres that are found at the ends of our chromosomes. They provide stability to this genetic material. As our telomeres get shorter and shorter, our cellular aging and, ultimately, biological aging, increases.

In a preliminary case control study, dementia patients were shown to have significantly shorter telomere length than healthy patients (2). Interestingly, according to the authors, men have shorter telomere length and may be biologically older by four years than women of the same chronological age. The researchers caution that this is a preliminary finding and may not have clinical implications.

What I find most intriguing is that intensive lifestyle modifications increased telomere length in a small three-month study with patients who had low-risk prostate cancer (3). By adjusting their lifestyles, study participants were potentially able to decrease their biological ages.

Diet’s effect

Lifestyle modifications play a role in many chronic diseases and disorders. Dementia is no exception. In a prospective observational study, involving 3,790 participants, those who had the greatest compliance with a Mediterranean-type diet demonstrated a significant reduction in the risk of Alzheimer’s disease, compared to the least compliant (4). Participants were over the age of 65, demographics included substantial numbers of both black and white participants, and there was a mean follow-up of 7.6 years. Impressively, those who adhered more strictly to the diet performed cognitively as if they were three years younger, according to the authors.

Beta-carotene and vitamin C effect

In a small, preliminary case-control study (disease vs. healthy patients), higher blood levels of vitamin C and beta-carotene significantly reduced the risk of dementia, by 71 percent and 87 percent, respectively (5). The blood levels were dramatically different in those with the highest and lowest blood levels of vitamin C (74.4 vs. 28.9 µmol/L) and beta-carotene (0.8 vs. 0.2 µmol/L).

The reason for this effect may be that these nutrients help reduce oxidative stress and thus have neuroprotective effects, preventing the breakdown of neurons. This study was done in the elderly, average 78.9 years old, which is a plus, since as we age we’re more likely to be afflicted by dementia.

It is critically important to delineate the sources of vitamin C and beta-carotene in this study. These numbers came from food, not supplements. Why is this important? First, beta-carotene is part of a family of nutrients called carotenoids. There are at least 600 carotenoids in food, all of which may have benefits that are not achieved when taking beta-carotene supplements. Second, beta-carotene in supplement form may increase the risk of small-cell lung cancer in smokers (6).

Foods that contain beta-carotene include fruits and vegetables such as berries; green leafy vegetables; and orange, red or yellow vegetables like peppers, carrots and sweet potato. In my practice, I test for beta-carotene and vitamin C as a way to measure nutrient levels and track patients’ progress when they are eating a nutrient-dense diet. Interestingly, many patients achieve more than three times higher than the highest beta-carotene blood levels seen in this small study.

Impact of high blood pressure medications

For those patients who have high blood pressure, it is important to know that not all blood pressure medications are created equal. When comparing blood pressure medications in an observational study, two classes of these medications stood out. Angiotensin II receptor blockers (known as ARBs) and angiotensin-converting enzyme inhibitors (known as ACE inhibitors) reduce the risk of dementia by 53 and 24 percent, respectively, when used in combination with other blood pressure medications.

Interestingly, when ARBs were used alone, there was still a 47 percent reduction in risk; however, ACE inhibitors lost their prevention advantage. High blood pressure is a likely risk factor for dementia and can also be treated with lifestyle modifications (7). Otherwise, ARBs or ACE inhibitors may be the best choices for reducing dementia risk.

Ginkgo biloba disappoints

Ginkgo biloba, a common herbal supplement taken to help prevent dementia, may have no benefit. In the GuidAge study, ginkgo biloba was shown to be no more effective than placebo in preventing patients from progressing to Alzheimer’s disease (8). This randomized controlled trial was done in elderly patients over a five-year period with almost 3,000 participants. There was no difference seen between the treatment and placebo groups. This reinforces the results of an earlier study, Ginkgo Evaluation of Memory trial (9). Longer studies may be warranted. The authors stressed the importance of preventive measures with dementia.

You may be able to prevent dementia, whether through lifestyle modifications or, if medications are necessary, through medication selection.

References:

(1) www.uptodate.com. (2) Arch Neurol. 2012 Jul 23:1-8. (3) Lancet Oncol. 2008;9(11):1048-1057. (4) Am J Clin Nutr. 2011;93:601-607. (5) J Alzheimers Dis. 2012;31:717-724. (6) Am. J. Epidemiol. 2009; 169(7):815-828. (7) Neurology. 2005;64(2):277. (8) Lancet Neurol. 2012;11(10):851-859. (9) JAMA. 2008;300(19):2253-2262.

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.      

20190102.01_New Childrens Signage and Lobby

By Margaret McGovern, M.D., Ph.D.

Dr. Margaret McGovern

Stony Brook Children’s Hospital offers the most advanced pediatric specialty care in the region, which means that the smallest babies, the sickest children and the most complex pediatric traumas all get sent to Stony Brook Children’s. 

Since 2010, when Stony Brook Children’s was first formed, we’ve been committed to the nearly half a million children in Suffolk County whose pediatric health care needs were underserved. Our goal was, and still is, to provide sophisticated pediatric care close to home for the many families who previously had to travel long distances.

Now with the completion and opening of our new building earlier this month, we are able to expand our capabilities to meet the growing health care needs of children and their families across Long Island. 

More than 180 pediatric specialists

As the leading children’s hospital on Long Island with more than 180 pediatric specialists in more than 30 specialties, we offer a full range of medical services to support the physical, emotional and mental development of infants, children and young adults. We also can provide leading-edge care for just about every diagnosis — from a simple fracture to a kidney transplant.

Groundbreaking clinical trials

Stony Brook Children’s also provides cutting-edge research, child-sized technological innovations, clinical trials and breakthrough techniques to benefit pediatric patients as Long Island’s only children’s teaching hospital.

A child-first, family-first philosophy

The new hospital was designed with patients at the center of our thinking and planning, to promote their safety, well-being and healing. It’s the only children’s hospital on Long Island with all single-patient rooms, which allows us to combine the best practices in modern pediatric medicine with a child-first, family-first philosophy. The hospital’s design and amenities are supported by research that shows that a child-friendly environment contributes to better outcomes for children.

Each room of the new hospital includes patient, family and health care provider areas. State-of-the-art hospital beds capture and download patient information directly into the patients’ charts. Every room contains a proprietary security system, interactive televisions, in-room refrigerators, kid-focused menus as well as multicolored wall lights controlled by patients to give them a greater sense of control over their environment during what can be a frightening time for them and their families.

Other child-friendly features include separate child and teen playrooms, common areas, including an outdoor garden, and a classroom with Wi-Fi so students can keep up with their studies.

There’s also a new Ronald McDonald Family Room to offer a welcoming place for family respite, comfort and support.

Uplifting local artwork that soothes and inspires 

We’ve enjoyed the support of Long Island’s artistic community in providing artwork with a Long Island nautical theme, complete with a play lighthouse and wall-sized live feed from the Long Island Aquarium. It’s truly an outstanding art collection for the entire community living in harmony with the building’s architecture and reflecting the healing mission of Stony Brook Children’s.

To learn more, visit www.stonybrookchildrens.org.

Dr. Margaret McGovern is the Knapp Chair in Pediatrics, dean for clinical affairs and Renaissance School of Medicine physician-in-chief at Stony Brook Children’s Hospital.

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#ResilientInSmithtown

November is Mental Health Awareness Month and the Town of Smithtown is seizing it as an opportunity to implement a social media campaign that highlights simple activities that help boost personal resilience. From Nov. 18 to 22, the Town’s Horizons Counseling & Education Center, the Youth Bureau and the Response Crisis Center will share advice, tips and resources to Twitter, Facebook and Instagram using the hashtag #ResilientInSmithtown. 

 This campaign is designed to educate residents about four kinds of personal attributes that boost mental well-being: physical, mental, emotional and social.  Strengthening these attributes contributes to living longer, happier lives, with a heightened ability to cope with life’s stressors. 

“This is a wonderful opportunity for residents to learn how they can have more control over their own personal resiliencies and be able to guide and support family members and friends,” said Stacey Standers, Town of Smithtown Youth Bureau executive director.

Residents of all ages are encouraged to participate in the educational campaign, which relies upon easy and fun exercises that will help Smithtown residents build upon their own personal strengths. 

Approximately one out of every five children in America has a diagnosable mental health disorder. Anxiety, depression and substance abuse are major issues impacting young people and their families, as well as schools and communities. Community education about the importance of bolstering one’s own personal resilience is beneficial at any age, town officials explain, and can be a vital component in maintaining mental health.

“There is a very clear and distinct correlation between childhood trauma and mental health issues and substance addiction,” said Matthew Neebe, director of Horizons Counseling & Education Center. “Problematic mental health issues experienced in childhood can very easily and often do follow individuals into maturity, creating a variety of long-term mental health issues that may cause self-medication through excessive drinking or substance abuse.” 

The campaign promotes scientifically validated activities that contribute to personal well-being. 

Physical resilience means the body can withstand more physical stress and heal itself faster. Mental resilience includes strengthening mental focus, discipline and will power, which is like a muscle that gets stronger the more it is exercised. Emotional resilience provokes powerful, positive emotions like curiosity or love, precisely when it’s needed the most. Social resilience strengthens from bonds with friends, family, neighbors and community.

Some of the recent posts include the following advice:

  • If you cannot change the situation, change your mind.
  • Once a situation is accepted for what it is, begin working on uncommon or creative solutions.
  • Humor can boost one’s mood, alleviate emotional distress and even buffer against depression.  Laughter and humor improve immune response, enhance perceptual flexibility and offset the effects of stress.
  • Positive reframing allows you to take control of your response to a situation by reframing it into a potential growth experience.
  • The first step of a good plan is to define what success looks like.

The postings are part of an ongoing campaign and represent one part of this initiative.

Look for Smithtown Youth Bureau on Facebook to find the different exercises and more information about #ResilientInSmithtown.

Reducing inflammation can reduce disease risk. Stock photo
C-reactive protein can be measured to identify disease risk

By David Dunaief, M.D.

One of the most widely studied biomarkers for inflammation in our bodies is high-sensitivity C-reactive protein (hsCRP), also referred to as CRP. High sensitivity means that we can measure levels as low as 0.3 mg/L more accurately.

What is the significance of the different levels? Individuals who have levels lower than 1.0 mg/L are in the optimal range for low risk for a host of diseases that are indicated by high inflammation. 

For example, with heart disease, levels of 1 to 3 mg/L represent the average risk range, and greater than 3.0 mg/L is a higher risk profile. Above 10.0 mg/L is more likely associated with other causes, such as infection and autoimmune diseases (1, 2). This biomarker is derived from the liver.

CRP is not specific to heart disease, nor is it definitive for risk of the disease. However, the upside is that it may be helpful with risk stratification, which helps us understand where we sit on a heart disease risk spectrum and with progression in other diseases, such as age-related macular degeneration, diabetic retinopathy, depression and autoimmune diseases. Let’s look at the evidence.

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Age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness in patients over the age of 65 (3). Therefore, it is very important to help define risk stratification for this disease. In a prospective study, results showed that hsCRP levels were inversely associated with the risk of developing AMD. The group with an hsCRP greater than 3.0 mg/L had a 50 percent increased risk of developing overall AMD compared to the optimal group with hsCRP lower than 1.0 mg/L. But even more interestingly, the risk of developing neovascular, or wet, AMD increased to 89 percent in this high-risk group.

The significance of wet AMD is that it is one type of advanced-stage AMD that results in blindness. This study involved five studies where the researchers thawed baseline blood samples from middle-aged participants who had hsCRP levels measured. There were more than 2,000 participants with a follow-up as long as 20 years. According to the study’s authors, annual eye exams and lifestyle modifications, including supplements, may be able to stem this risk by reducing hsCRP.

These results reinforce those of a previous prospective study that showed that elevated hsCRP increased the risk of AMD threefold (4). This study utilized data from the Women’s Health Study, which involved over 27,000 participants. Like the study mentioned above, this one also defrosted blood samples from baseline and looked at follow-up incidence of developing AMD in initially healthy women.

The highest group had hsCRP levels over 5.2 mg/L. Additionally, when analyzing similar cutoffs for high- and low-level hsCRP, as the above trial used, those with hsCRP over 3.0 had an 82 percent increased risk of AMD compared to those with an hsCRP of lower than 1.0 mg/L.

Diabetic retinopathy

We know that diabetes affects just under 10 percent of the U.S. population and is continuing to rise. One of the complications of diabetes is diabetic retinopathy, which affects the retina (back of the eye) and is a leading cause of vision loss (5). One of the reasons for the vision loss is macular edema, or swelling, usually due to rupture of tiny blood vessels below the macula, a portion of the back of the eye responsible for central vision.

The Diabetes Control and Complications Trial (DCCT), a prospective study involving over 1,400 Type 1 diabetes patients, showed an 83 percent increased risk of developing clinically significant macular edema in the group with the highest hsCRP levels compared to those with the lowest (6). Although these results were with Type 1 diabetes, patients with Type 2 diabetes are at equal risk of diabetic retinopathy if glucose levels, or sugars, are not well controlled.

Depression

Depression is a very difficult disease to control and is a tremendous cause of disability.

Well, it turns out that inflammation is associated with depression. Specifically, in a prospective observational trial, rising levels of CRP had a linear relationship with increased risk of hospitalization due to psychological distress and depression (7). In other words, compared to levels of less than 1 mg/L, those who were 1 to 3 mg/L, 3 to 10 mg/L and greater than 10 mg/L had increased risk from 30 to 84 to 127 percent, respectively. This study involved over 70,000 patients.

How can you reduce inflammation?

This is the key question, since we now know that hsCRP is associated with systemic inflammation. In the Nurses’ Health Study, a very large, prospective observational study, the Dietary Approaches to Stop Hypertension (DASH) diet decreased the risk of both heart disease and stroke, which is impressive. The DASH diet also decreases the levels of hsCRP significantly, which was associated with a decrease in clinically meaningful end points of stroke and heart disease (8). The DASH diet is nutrient dense with an emphasis on fruits, vegetables, nuts, seeds, legumes and whole grains and a de-emphasis on processed foods, red meats, sodium and sweet beverages.

Conclusion

As the evidence shows with multiple diseases, hsCRP is a very valuable nonspecific biomarker for inflammation in the body. To stem the effects of inflammation, reducing hsCRP through lifestyle modifications and drug therapy may be a productive way of reducing risk, slowing progression and even potentially reversing some disease processes.

The DASH diet is a very powerful approach to achieving optimal levels of hsCRP without incurring potential side effects. This is a call to arms to have your levels measured, especially if you are at high risk or have chronic diseases such as heart disease, diabetes, depression and autoimmune diseases. HsCRP is a simple blood test with easy-to-obtain results.

References:

(1) uptodate.com. (2) Diabetes Technol Ther. 2006;8(1):28-36. (3) Prog Retin Eye Res. 2007 Nov;26(6):649-673. (4) Arch Ophthalmol. 2007;125(3):300-305. (5) Am J Ophthalmol. 2003;136(1):122-135. (6) JAMA Ophthalmol. 2013 Feb 7;131:1-8. (7) JAMA Psychiatry. 2013;70(2):176-184. (8) Arch Intern Med. 2008;168(7):713-720.

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.      

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Enrico Scarda, owner of Danfords, with Jami Cohen at the fundraiser for her sister. Photo by Julianne Mosher

By Julianne Mosher

The Brookhaven Ballroom at Danfords was filled with hundreds of people to celebrate and support one of their own this week through the family’s bout with cancer.

Dara Cohen. photo from Dara’s GoFundMe health fund

Dara Cohen, originally of Dix Hills, has been living under the weight of cancer for years, battling Stage 4 breast, brain and lung cancer, and now friends said it has metastasized in her lower spinal cord. The actress and professional dancer works as a ballet teacher when she feels up to it, but the disease has had a lasting effect.

It was just a few months ago when Dara Cohen’s sister, Jami, who bartends at the hotel in PJ, came to work and asked her managers if they could help her create a fundraiser. 

The goal was to raise $100,000 for the 46-year-old dancer, singer and actress. 

“They immediately said yes,” Jami Cohen, of Port Jefferson, said. “I couldn’t ask for better people to work with.”

On Monday, Nov. 11, Danfords donated its space upstairs and an extensive menu at its buffet to the Cohen family. 

“Obviously it’s an unbelievable cause,” Enrico Scarda, owner of Danfords, said, “And we do whatever we can to support our employees.”

Lamar Peters with Gail King and Shelly Cohen. Photo by Julianne Mosher

A DJ blasted music while people mingled. Lamar Peters, a tribute artist known for his Elvis, Johnny Cash and Buddy Holly impersonations, came out to play, and over 100 gifts were donated to the raffle table. 

“All of us are here to unite and break course for Dara,” Dara’s father Shelly Cohen said. “We’re looking to make a difference and these people are coming out to help our daughter.”

Tickets were $40 for the three-hour event and the outcome was a huge success. Although Dara couldn’t be in attendance, she video-called in and was grateful for the response given in her honor. 

Known for her popular social media posts chronicling her journey, Dara’s goal has been to help other people struggling as well. 

“She’s an amazing person,” Dara’s mother Karen Deangelis, said. “Dara has made an impact on other people and has a tremendous amount of support … Hopefully we can help other people, too.”

Students and parents address the board during a standing-room only board meeting Nov. 7, after air quality issues have resurfaced at Northport Middle School. Photos by David Luces

A day that began with over 60 parents and children participating in a “sickout” protest in front of Northport Middle School ended with a public meeting later that night, where the seven-member board of education unanimously voted to begin soil testing at the school. 

A packed crowd at the boarding meeting Nov. 7. Photos by David Luces

A crowd of concerned parents and community members packed into the standing room only public meeting at the William Brosnan School. Many parents voiced dissatisfaction about how the school district has been handling recent incidents with foul odors at the middle school, saying that soil and groundwater testing are long overdue.

Many people blamed illnesses, such as cancer, headaches, nosebleeds, mold infections and other serious diseases, on the school’s long history of air quality issues. 

Board President David Badanes and Superintendent Robert Banzer both reiterated to the crowd that according to experts, the middle school is safe for operations.

“Since 2017, we have made major capital and personnel improvements to the school and have corrected issues found in a 65-year-old building, as well conducted environmental testing and engaged experts from the Department of Health, the Occupational and Environmental Medicine Center of Long Island and the Icahn School of Medicine,” Banzer said. “In their professional assessments, all have indicated that the middle school is safe for occupancy. Without the assurances of these professionals we would have not occupied the school.”

“In their professional assessments, all have indicated that the middle school is safe for occupancy. Without the assurances of these professionals we would have not occupied the school.”

– Robert Banzer

The district expects that soil testing and the creation of a subcommittee will quell any remaining concerns and help bring a divided community back together. 

The subcommittee will be made up of 10 members, which will include board trustees, parents, district staff and professional experts. Together they will work on an analysis and come up with parameters of the soil testing. 

The timetable for the subcommittee’s actions has already been established. On Dec. 12, recommendations will be given to the board identifying experts that will conduct soil testing and additional analysis. December through January, soil testing begins. January-February, assessment of soil testing results. By March, the district expects a final report, which will include recommendations given to the board.  

Parent Lauren Handler called on the board to stop utilizing the services of Hauppauge-based firm J.C. Broderick, which has come under scrutiny for some of its previous reports and findings at the middle school. 

She also asked for a comprehensive review of all previous testing done at the school, additional groundwater testing, cesspool testing, and investigating the environmental impact of the VA Hospital and Covanta among other things. 

“If any part of this testing cannot be completed, or if testing is completed and the source of the result cannot be identified and remediated, than this building should be closed,” Handler said. “If this request cannot be met, I’m asking the superintendent and board members to step down.”

 A number of speakers called on the board to consider appointing an independent broker to select the consultant and experts that will be on the committee. 

Tammie Topel, a former board member who served for six years, said she previously brought up health concerns to the board.

A Northport Middle School student addresses the board Nov. 7. Photos by David Luces

“I am a former board member and when I was on the board two years ago, I requested for soil testing more than once,” she said. “Especially during one of my final board meetings, when I learned two former students had developed aplastic anemia.”

Topel, a nurse by profession, said proposals to approve soil testing at the middle school were voted down twice during her tenure. 

“Why didn’t we do this two years ago?” she asked. 

A number of parents also accused the board of not being up front with information about student illnesses at the school.

“I’m alarmed and disgusted by some of these things I just learned recently,” Michael Figeroura, an emergency medical technician for the New York City Fire Department and parent, said. “I find it disgusting when kids are complaining that they have headaches or smelling metallic things, they go to the nurse and all that gets done is that they check their temperature.”   In addition, Figeroura criticized Timothy Hoss, Northport Middle School Principal, for his handling of the situation.

“Who tells them [the students] after he comes into the room that there’s nothing there … But miraculously 30 minutes later there’s an email, a text message and a phone call — that yes there was some type of smell in the air and that they are working on the ventilation systems,” he said. “I want something to be done, we absolutely need more testing now and later.”

He also called for better trained medical staff in the schools. 

“For a nurse to check the temperature of a child after they complained about metallic smells, it is unacceptable,” Figeroura said. 

Timothy Heck, an accountant and community member, was one of a number of individuals that proposed the idea of moving the middle school students to another building in the district, arguing that the district has the available space due to declining enrollment. 

“I did a rough estimate myself and I figured from the administrative and operation costs, it costs around $2.5 to $5 million to keep one of the schools open,” he said. “What makes sense to me is that you could close one of the schools down and move the kids to this building or one of the grade schools.”

Heck cited a 2015 demographic study done by the district, where they projected that about 502 students were expected to be enrolled in the middle school in 2024 compared to 2007 when it had a peak of 908 students. 

Similarly, at a board of education budget meeting in January, the district projected that the schools have lost nearly 1,165 students since the 2011-12 school year. 

It’s unclear if board members are considering that option. 

Three board of education trustees have been appointed to the committee: Vicky Buscareno, Larry Licopoli and Tom Loughran. If you are interested in being considered for the subcommittee please send an email to: boe@northport.k12.ny.us.

 

Pedometers may help achieve exercise goals

By David Dunaief, M.D.

Dr. David Dunaief

Chronic obstructive pulmonary disease, or COPD, is the third leading cause of mortality in the United States, although it’s not highlighted much in the layman’s press (1).

COPD is an umbrella term that includes emphysema, chronic bronchitis of more than three months for two consecutive years and/or chronic obstructive asthma. It is an obstructive lung disease that limits airflow. The three most common symptoms of the disease involve shortness of breath, especially on exertion, production of sputum and cough. This disease affects 6.7 percent of the U.S. population (2).

It tends to be progressive, meaning more frequent and severe exacerbations over time. Since it is a devastating and debilitating chronic disease with no cure, anything that can identify and prevent COPD exacerbations, as well as comorbidities (associated diseases), is critically important.

What are the traditional ways to reduce the risk of and treat COPD exacerbations? The most important step is to stop smoking, since 80 percent of COPD is related to smoking. Supplemental oxygen therapy and medications, such as corticosteroids, bronchodilators (beta-adrenergic agonists and anticholinergics) and antibiotics help to alleviate symptoms (3).

One of the underlying components of COPD may be chronic inflammation (4). Therefore, reducing inflammation may help to stem COPD exacerbations. There are several inflammatory biomarkers that could potentially help predict exacerbations and mortality associated with this disease, such as interleukin-6 (IL-6), C-reactive protein (CRP), leukocyte (white blood cell) count and fibrinogen (a clotting factor of the blood).

How do we reduce inflammation, which may contribute to exacerbations of this disease? Some drugs, such as statins, work partially by reducing inflammation. They may have a role in COPD. Lifestyle changes that include a high-nutrient, anti-inflammatory diet and exercise may also be beneficial.

Let’s look at the evidence.

Biomarkers for inflammation

In a population-based study with over 60,000 participants, results show that as three biomarkers (CRP, leukocyte count and fibrinogen) were elevated, the risk of COPD exacerbation increased in a linear manner (5). In other words, the risk of frequent exacerbation increased 20, 70 and 270 percent within the first year as the number of elevated biomarkers increased from one to three, compared to patients who did not have biomarker elevations.

As time progressed beyond the first year of follow-up, risk exacerbation continued to stay high. Patients with all three biomarkers elevated for longer periods had a 150 percent increased risk of frequent exacerbations. These predictions were applicable to patients with stable and with mild COPD.

In an observational study, results showed that when the biomarker IL-6 was elevated at the start of the trial in stable COPD patients, the risk of mortality increased almost 2.7-fold (6). Also, after three years, IL-6 increased significantly. Elevated IL-6 was associated with a worsening of six-minute walking distance, a parameter tied to poor physical performance in COPD patients. However, unlike the previous study, CRP did not show correlation with increased COPD exacerbation risk. This was a small trial, only involving 53 patients. Therefore, the results are preliminary.

These biomarker trials are exciting for their potential to shape treatments based on level of exacerbation risk and mortality, creating more individualized therapies. Their results need to be confirmed in a randomized controlled trial (RCT). Many of these biomarkers mentioned in the two trials are identifiable with simple blood tests at major labs.

Statin effect

Statins have been maligned for their side effects, but their efficacy has been their strong suit. An observational trial showed that statins led to at least a 30 percent reduction in the risk of COPD exacerbations, with the effect based on a dose-dependent curve (7). In other words, as the dose increased, so did the benefit.

Interestingly, even those who had taken the statin previously saw a significant reduction in COPD exacerbation risk. The duration of statin use was not important; a short use of statins, whether presently or previously, had substantial benefit. However, the greatest benefit was seen in those who had been on a medium to high dose or were on the drug currently. The researchers believe that the mechanism of action for statins in this setting has to do with their anti-inflammatory and immune-modulating effects. This was a retrospective (backward-looking) study with over 14,000 participants. We will need a prospective (forward-looking) study and an RCT to confirm the results.

Exercise

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Exercise is beneficial for almost every circumstance, and COPD is no exception. But did you know that a pedometer might improve results? In a three-month study, those with mild COPD were much more successful at achieving exercise goals and reducing exacerbations and symptoms when they used pedometers, compared to the group given advice alone (8). Pedometers gave patients objective feedback on their level of physical activity, which helped motivate them to achieve the goal of walking 9,000 steps daily. This is a relatively easy way to achieve exercise goals and reduce the risk of COPD exacerbations.

When exercising, we are told to vary our exercise routines on regular basis. One study demonstrates that this may be especially important for COPD patients (9). Results show that nonlinear periodization exercise (NLPE) training is better than traditional routines of endurance and resistance training in severe COPD patients. The goal of NLPE is to regularly alter the time spent working out, the number of sets, the number of repetitions and the intensity of the workout on a regular basis.

This study was randomized, involved 110 patients and was three months in duration. Significantly more severe COPD patients achieved their exercise goals using NLPE than the traditional approach. The group that used NLPE also had an improved quality of life response. The researchers believe that compliance with an NLPE-type program is mostly likely going to be greater because patients seem to enjoy it more.

Chronic inflammation may play a central role in COPD exacerbation. Nonspecific inflammatory biomarkers are potentially valuable for providing more personalized approach to therapy. Drugs that can control inflammation, such as statins, show promise. But don’t forget the importance of lifestyle changes, such as quitting smoking and committing to an exercise regimen that is varied and/or involves the use of a pedometer. And potentially a high-nutrient, anti-inflammatory diet will also contribute positively to reducing the frequency and severity of COPD exacerbations.

References:

(1) Natl Vital Stat Rep. 2011 Dec.;59(10):1-126. (2) cdc.gov. (3) N Engl J Med. 2002;346:988-994. (4) www.goldcopd.org. (5) JAMA. 2013;309:2353-2361. (6) Respiratory Research. 2013;14:24. (7) Am J Med. 2013 Jul;126:598-606. (8) ATS 2013 International Conference: Abstract A1360. (9) Am J Respir Crit Care Med. 2013; online Feb. 28.

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.