Health

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

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

Impact on diabetes

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

Diabetic retinopathy

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

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

Age-related macular degeneration

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

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

Cardiovascular disease

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

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

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

References:

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

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician. 

Brian O’Reilly with Leg. Rob Trotta at a recent car wash fundraiser

Superheroes needed

Eagle Scout Brian O’Reilly will host a Bone Marrow Donor Drive at Smith Haven Mall’s Center Court in Lake Grove on Saturday, Sept. 21 from 11 a.m. to 4 p.m.

Brian is a sophomore at Smithtown High School West and a member of Boy Scout Troop 888. The event will benefit the Gift of Life for his Eagle Scout Project. Participation in the bone marrow drive is for people between the ages of 17 and 35. All a potential donor has to do is answer a few questions and get a quick swab of his/her cheeks. It takes just a minute to save a person’s life. “I think Brian is doing a terrific project that could benefit so many people,” said Suffolk County Legislator Rob Trotta.

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

Is it important to get screened?

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

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

What are the treatments?

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

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

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

Lifestyle changes

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

Smoking cessation

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

Impact of fruit

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

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

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

References:

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

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.         

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The Suffolk County Department of Health announced 11 more mosquito samples have tested positive for West Nile Virus, with two samples collected in Rocky Point, one sample from Northport, one from Melville and one from Greenlawn.

Other samples were collected in Holtsville, Mattituck and Greenlawn.

New York State’s health department informed Suffolk County health officials Sept. 13 the new samples bring the total reports of West Nile Virus amongst mosquitos to 68. Four birds have tested positive for West Nile so far, but no humans or horses have tested positive in Suffolk County.

Dr. James Tomarken, the county commissioner of health, reiterated the need for people to report dead birds or look for other symptoms of the virus.

“The confirmation of West Nile virus in mosquito samples or birds indicates the presence of West Nile virus in the area,” he said.

Last month, 10 other mosquito samples tested positive for the virus. Three samples had been found in Rocky Point, with others located in Commack and Huntington Station, among others.

West Nile virus may cause a range of symptoms, from mild to severe, including fever, headache, vomiting, muscle aches, joint pain and fatigue. There is no specific treatment for West Nile virus. Patients are treated with supportive therapy as needed.

The best way to handle local mosquito populations is for residents to eliminate standing or stagnant water pools in their local areas.

People are also encouraged to use long sleeves and socks and use mosquito repellent.

The virus came to New York nearly 20 years ago, and samples are usually found in summertime when the mosquito population is most active. Cases, in the intervening years, have become relatively rare.

Dead birds may indicate the presence of West Nile virus in the area. To report dead birds, call the Public Health Information Line in Suffolk County at 631-787-2200 from 9 a.m. to 4:30 p.m., Monday through Friday. Residents are encouraged to take a photograph of any bird in question.

To report mosquito problems or stagnant pools of water, call the Department of Public Works’ Vector Control Division at 631-852-4270.

The use of Narcan is demonstrated on a dummy during a training class. File photo by Elana Glowatz

At Stony Brook University Renaissance School of Medicine, a new generation of doctors and dentists are involved in a novel approach to managing the opioid epidemic. The training includes instruction from reformed narcotic users, who act as teachers.

A 25-year-old woman recently explained to the first-year students how she became addicted to opioids at the age of 15, when a friend came over with Vicodin prescribed by a dentist after a tooth extraction.

Addiction, she said, is like having a deep itch inside that desperately needs to be scratched.

“There was nothing that could stand between me and getting high,” said the young woman, who wants to remain anonymous. “Most of the time it was my only goal for the day. At $40 a pill, I quickly switched to heroin which costs $10.” 

The university’s Assistant Dean for Clinical Education Dr. Lisa Strano-Paul, who helped coordinate the session, said that “patients as teachers” is widely practiced in medical education. This is the first year reformed narcotic users are participating in the program.

“People’s stories will stick with these medical students for the rest of their lives,” she said. “Seeing such an articulate woman describe her experiences was impactful.”

Gerard Fischer, a doctor of dental surgery candidate from St. James, took part in the patient-as-teacher session on narcotics.

“You learn empathy, a quality people want to see in someone practicing medicine,“ Fischer said. “People don’t choose to become addicted to narcotics. So, you want to understand.”

After working in dental offices over the last several years, he’s noticed that habits for prescribing painkillers are changing.

“Dental pain is notoriously uncomfortable because it’s in your face and head,” he said. “No one wants a patient to suffer.” Pain management, though, requires walking a fine line, he added, saying, “Patient awareness is increasing, so many of them now prefer to take ibuprofen and acetaminophen rather than a prescription narcotic, which could be a reasonable approach.”

Hearing the young woman tell her story, he said, will undoubtedly influence his decision-making when he becomes a practicing dentist. 

An estimated 180 medical and dental students attended the training last month. Overall, Strano-Paul said she’s getting positive feedback from the medical students about the session. 

The woman who overcame addiction and shared her insights with the medical professionals, also found the experience rewarding. 

We respect her request to remain anonymous and are grateful that she has decided to share her story with TBR News Media. For the rest of this article, we shall refer to her as “Claire.” 

Faith, hope and charity

“I told the doctors that recovery has nothing to do with science,” Claire said. “They just looked at me.”

Claire was addicted to drugs and alcohol for seven years and went to rehab 10 times over the course of five years. 

“I did some crazy things, I jumped out of a car while it was moving,” Claire said, shaking her head in profound disbelief.

She leapt from the vehicle, she said, the moment she learned that her family was on their way to a rehab facility. Fortunately, she was unharmed and has now been off pain pills and drugs for close to six years. She no longer drinks alcohol.

“Yes, it is possible to recover from addiction,” Claire said. 

People with addiction issues feel empty inside, Claire explained, while gently planting her fist in her sternum. She said that once her counselor convinced her to pray for help and guidance, she was able to recover.

“Somehow praying opens you up,” she said. 

Claire was raised Catholic and attended Catholic high school but says that she’s not a religious person. 

“I said to my counselor, “How do I pray, if I don’t believe or know if there’s a God?” 

She came to terms with her spirituality by appreciating the awe of nature. She now prays regularly. Recovery, she said, is miraculous.

Alcoholics Anonymous’ 12-step regimen, first published in 1939 in the post-Depression era, outlines coping strategies for better managing life. Claire swears by the “big book,” as it’s commonly called. She carefully read the first 165 pages with a counselor and has highlighted passages that taught her how to overcome addictions to opioids and alcohol. Being honest, foregoing selfishness, praying regularly and finding ways to help others have become reliable sources of her strength.

Spirituality is the common thread Claire finds among the many people she now knows who have recovered from addiction.

The traditional methods of Alcohol Anonymous are helping people overcome addiction to opioids.

Medication-assisted therapy

Personally, Claire recommends abstinence over treating addiction medically with prescription drugs such as buprenorphine. The drug, approved by the U.S. Food & Drug Administration since 2002, is a slow-release opioid that suppresses symptoms of withdrawal. When combined with behavior therapy, the federal government recommends it as treatment for addiction. Medication alone, though, is not viewed as sufficient. The ultimate goal of medication-assisted therapy, as described on the U.S. Department of Health & Human Services website on the topic, is a holistic approach to full recovery, which includes the ability to live a self-directed life.

“Medication-assisted therapy should not be discounted,” Strano-Paul said. “It improves the outcome and enables people to hold jobs and addresses criminal behavior tendencies.”

While the assistant dean is not involved with that aspect of the curriculum, the topic is covered somewhat in the clerkship phase of medical education during sessions on pain management and when medical students are involved in more advanced work in the medical training, she said. 

The field, though, is specialized.

The federal government requires additional certification before a medical practitioner can prescribe buprenorphine. Once certified, doctors and their medical offices are further restricted to initially prescribe the medicine to only 30 patients annually. Critics say no other medications have government-mandated patient limits on lifesaving treatment. 

The Substance Abuse and Mental Health Services Administration, a division of the U.S. Department of Health & Human Services, considers the therapy to be “misunderstood” and “greatly underused.” 

In New York state, 111,391 medical practitioners are registered with the U.S. Drug Enforcement Administration to prescribe opioids and narcotics. Only 6,908 New York practitioners to date are permitted to prescribe opioids for addiction treatment as at Aug. 31.

Strano-Paul for instance, pointed out that she can prescribe opioids, but is prohibited from prescribing the opioid-based drug used for addiction therapy. 

The narcotics education program is still evolving, Strano-Paul said. 

New medical student training now also includes certification for Narcan, the nasal spray antidote that revives opioid overdose victims. 

“It saves lives,” Strano-Paul said. 

In Suffolk County in 2017, 424 people died from an opioid overdose, which was 41 percent higher than the state average, according to a study titled “The Staggering Cost of Long Island’s Opioid Crisis.” The county is aware of 238 potentially lifesaving overdose reversals as of June 30 attributed to Narcan this year alone. Since 2012, Narcan has helped to save the lives of 3,864 people in the county. 

As for Claire, now a mother, she delivered her children through C-section. In the hospital, she was offered prescription opioids for pain. 

“No one will ever see me again, if you give me those pills,” she said.                

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Lifestyle changes put you in control

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

4. Vitamin D deficiency may contribute to cardiovascular disease.

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

Fish oil

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

Fiber

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

Diet soda

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

Vitamin D

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

What have we learned?

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

References:

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

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician. 

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The state health department said 10 mosquito samples tested positive for West Nile virus in Suffolk County at the end of August, with three samples being found in Rocky Point.

In a release Aug. 30, Suffolk County Department of Health said that the mosquito samples, collected Aug. 20 and 21, had examples of West Nile virus in Lindenhurst, North Babylon, Farmingville, West Babylon, North Patchogue, Huntington Station, Commack and Rocky Point. All but Rocky Point had only one such sample collected.

Suffolk County has reported 53 mosquito samples to date that have tested positive for West Nile and six for Easter equine encephalitis, a virus that can cause brain infections, though no new samples have been collected at this point.

Dr. James Tomarken, the county commissioner of health, said there is a presence, but there is no reason to panic.

“The confirmation of West Nile virus in mosquito samples or birds indicates the presence of West Nile virus in the area,” said Tomarken. “While there is no cause for alarm, we advise residents to cooperate with us in our efforts to reduce their exposure to the virus, which can be debilitating to humans.”

West Nile virus may cause a range of symptoms, from mild to severe, including fever, headache, vomiting, muscle aches, joint pain and fatigue. There is no specific treatment for West Nile virus. Patients are treated with supportive therapy as needed.

The best way to handle local mosquito populations is for residents to eliminate standing or stagnant water pools in their areas. Tomarken said it’s important for residents to stay vigilant especially if they enter the Manorville area.

People are also encouraged to use long sleeves and socks and use mosquito repellent.

Dead birds may indicate the presence of West Nile virus in the area. To report dead birds, call the Public Health Information Line in Suffolk County at 631-787-2200 from 9 a.m. to 4:30 p.m., Monday through Friday. Residents are encouraged to take a photograph of any bird in question.

To report mosquito problems or stagnant pools of water, call the Department of Public Works’ Vector Control Division at 631-852-4270.

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

Heart disease’s impact

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

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

Stroke location vs. frequency

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

Exercise’s effects

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

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

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

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

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

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

Diet’s effects

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

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

References:

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

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician. 

Photo from Northwell Health

Huntington Hospital has received a two-year designation as an Antimicrobial Stewardship Center of Excellence (AS CoE) by the Infectious Diseases Society of America (IDSA). The hospital is one of only 35 hospitals nationwide to receive this recognition.

More than 700,000 people die worldwide each year due to antimicrobial-resistant infections. The AS CoE program recognizes institutions that have created stewardship programs led by infectious disease (ID) physicians and ID-trained pharmacists who have achieved standards established by the Centers for Disease Control and Prevention (CDC). The CDC core elements for antibiotic stewardship include seven major areas: leadership commitment, accountability, drug expertise, action, tracking, reporting and education.

Dr. Cynthia Ann Hoey and Dr. Adrian Popp, infectious disease specialists, worked closely with pharmacists Agnieszka Pasternak  and Nina Yousefzadeh to ensure Huntington Hospital met the rigorous criteria to be recognized by the IDSA.

“We are honored to have received this prestigious IDSA recognition,” said Dr. Nick Fitterman, the hospital’s executive director. “We are committed to fighting antimicrobial resistance through our comprehensive training and educational outreach program with all of our infectious disease specialists and pharmacists. The antimicrobial stewardship program will improve patient care and preserve the integrity of current treatments for future generations.”

Pictured from left, Nina Yousefzadeh,  Dr. Cynthia Ann Hoey, Agnieszka Pasternak and Dr. Nick Fitterman.

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

Effect of refined carbohydrates

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

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

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

Comparing macronutrients

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

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

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

Impact of obesity

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

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

Steroid levels

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

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

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

References:

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

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