Medical Compass

Gluten is found mainly in wheat, rye and barley. Stock photo
Antibiotics may contribute to celiac disease

By David Dunaief, M.D.

Dr. David Dunaief

Gluten-free diets are a hot topic. When we hear someone mention a gluten-free diet, we may automatically think that this is a healthy diet. However, gluten-free is not necessarily synonymous with healthy. There are many beneficial products containing gluten.

Still, we keep hearing how more people feel better without gluten. Could this be a placebo effect? What is myth and what is reality in terms of gluten? In this article I will try to distill what we know about gluten and gluten-free diets, who may benefit and who may not.

But first, what is gluten? Gluten is a plant protein found mainly in wheat, rye and barley.

While more popular recently, going gluten-free is not a fad, since we know that patients who suffer from celiac disease, an autoimmune disease, benefit tremendously when gluten is removed (1). In fact, it is the main treatment.

But what about people who don’t have celiac disease? There seems to be a spectrum of physiological reaction to gluten, from intolerance to gluten (sensitivity) to gluten tolerance (insensitivity). Obviously, celiac disease is the extreme of intolerance, but even these patients may be asymptomatic. Then, there is nonceliac gluten sensitivity (NCGS), referring to those in the middle portion of the spectrum (2). The prevalence of NCGS is half that of celiac disease, according to the NHANES data from 2009-2010 (3). However, many disagree with this assessment, indicating that it is much more prevalent and that its incidence is likely to rise (4). The term was not even coined until 2011.

What is the difference between full-blown celiac disease and gluten sensitivity? They both may present with intestinal symptoms, such as bloating, gas, cramping and diarrhea, as well as extraintestinal (outside the gut) symptoms, including gait ataxia (gait disturbance), malaise, fatigue and attention deficit disorder (5). Surprisingly, they both may have the same results with serological (blood) tests, which may be positive or negative. The first line of testing includes anti-gliadin antibodies and tissue transglutaminase. These measure a reaction to gluten; however, they don’t have to be positive for there to be a reaction to gluten. HLA–DQ phenotype testing is the second line of testing and tends to be more specific for celiac disease.

What is unique to celiac disease is a histological change in the small intestine, with atrophy of the villi (small fingerlike projections) contributing to gut permeability, what might be called “leaky gut.” Biopsy of the small intestine is the most definitive way to diagnose celiac disease. Though the research has mainly focused on celiac disease, there is some evidence that shows NCGS has potential validity, especially in irritable bowel syndrome.

Before we look at the studies, what does it mean when a food says it’s “gluten-free”? Well, the FDA has weighed in by passing regulation that requires all gluten-free foods to have no more than 20 parts per million of gluten (6).

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a nebulous disease diagnosed through exclusion, and the treatments are not obvious. That is why the results from a 34-patient, randomized controlled trial, the gold standard of studies, showing that a gluten-free diet significantly improved symptoms in IBS patients, is so important (7). Patients were given a muffin and bread on a daily basis.

Of course, one group was given gluten-free products and the other given products with gluten, though the texture and taste were identical. In six weeks, many of those who were gluten-free saw the pain associated with bloating and gas mostly resolve; significant improvement in stool composition, such that they were not suffering from diarrhea; and their fatigue diminished. In fact, in one week, those in the gluten group were in substantially more discomfort than those in the gluten-free group.

As part of a well-written March 4, 2013 editorial in Medscape by David Johnson, M.D., a professor of gastroenterology, questions whether this beneficial effect from the IBS trial was due to gluten withdrawal or to withdrawal of fermentable sugars because of the elimination of some grains themselves (8). In other words, gluten may be just one part of the picture. He believes that nonceliac gluten sensitivity is a valid concern.

Antibiotics

The microbiome in the gut may play a pivotal role as to whether a person develops celiac disease. In an observational study using data from the Swedish Prescribed Drug Register, results indicate that those who were given antibiotics within the last year had a 40 percent greater chance of developing celiac disease and a 90 percent greater risk of developing inflammation in the gut (9). The researchers believe that this has to do with dysbiosis, a misbalance in the microbiota, or flora, of the gastrointestinal tract. It is interesting that celiac disease may be propagated by change in bacteria in the gut from the use of antibiotics.

Not everyone will benefit from a gluten-free diet. In fact, most of us will not. Ultimately, people who may benefit from this type of diet are those patients who have celiac disease and those who have symptomatic gluten sensitivity. Also, patients who have positive serological tests, including tissue transglutaminase or anti-gliadin antibodies, are good candidates for gluten-free diets.

There is a downside to a gluten-free diet: potential development of macronutrient and micronutrient deficiencies. Therefore, it would be wise to ask your doctor before starting gluten withdrawal. The research in patients with gluten sensitivity is relatively recent, and most gluten research has to do with celiac disease. Hopefully, we will see intriguing studies in the near future.

References:

(1) Am J Gastroenterol. 2013;108:656-676. (2) Gut 2013;62:43–52. (3) Scand J Gastroenterol. (4) Neurogastroenterol Motil. 2013 Nov;25(11):864-871. (5) medscape.com. (6) fda.gov. (7) Am J Gastroenterol. 2011; 106(3):508-514. (8) medscape.com. (9) BMC Gastroenterol. 2013:13(109).

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.

Lyme disease starts with a circular rash where the ticks bite. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Ah, summer is upon us. Unfortunately, this means that tick season is getting into full swing.Thus, it is good timing to talk about Borrelia burgdorferi, better known as the bacterium that causes Lyme disease. This bacterium is from the spirochete class and is typically found in the deer tick, also known as the blacklegged tick.

What do deer ticks look like? They are small and can be as tiny as a pencil tip or the size of a period at the end of a sentence. The CDC.gov site is a great resource for tick images and other information related to Lyme disease.

If you have been bitten by a tick, the first thing you should do is remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick, for doing so may spread infectious disease (1). In a study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The National Institutes of Health recommend not removing a tick with oil (2).

When a tick is removed within 36 to 48 hours, the risk of infection is quite low (3). However, a patient can be given a prophylactic dose of the antibiotic doxycycline, one dose of 200 mg, if the erythema migrans, or bulls-eye rash — a red outer ring and red spot in the center — has not occurred, and it is within 72 hours of tick removal (4). Those who took doxycycline had significantly lower risk of developing the bulls-eye rash and thus Lyme disease; however, treatment with doxycycline did have higher incidence of nausea and vomiting than placebo.

What are the signs and symptoms of Lyme disease? There are three stages of Lyme disease: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue (54 percent), muscle pain and joint pain (44 percent), headache (42 percent), neck stiffness (35 percent), swollen glands (23 percent) and fever (16 percent) (5).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory radiculoneuropathy (nerve roots of spinal cord). Late disseminated disease can cause Lyme arthritis (inflammation in the joints), heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (2).

How do we prevent Lyme? According to the Centers for Disease Control and Prevention, we should wear protective clothing, spray ourselves with insect repellent that includes at least 20 percent DEET and treat our yards (3). Always check your skin and hair for ticks after walking through a woody or tall grassy area. Many of us on Long Island have ticks in the yard, so remember to check your pets; even if treated, they can carry ticks into the house.

Diagnosis of Lyme disease

Many times Lyme disease can be diagnosed within the clinical setting. When it comes to serologic or blood tests, the CDC recommends an ELISA test followed by a confirmatory Western blot test (3). However, testing immediately after being bitten by a tick is not useful, since the test will tend to be negative, regardless of infection or not (4). It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (5). These antibodies sometimes remain elevated even after successful treatment with antibiotics.

The cardiac impact

Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death due to second- or third-degree atrioventricular (AV) node conduction (electrical) block. Among the 1.1 percent who had Lyme carditis, there were five sudden deaths (6). If there are symptoms of chest pain, palpitations, light-headedness, shortness of breath or fainting, then clinicians should suspect Lyme carditis.

Does chronic Lyme disease exist?

There has been a debate about whether there is something called “chronic Lyme” disease. The research, unfortunately, has not shown consistent results that indicate that it exists. In one analysis, the authors note that the definition of chronic Lyme disease is obfuscated and that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes, according to several prospective trials (7). The authors do admit that there are prolonged neurologic symptoms in a subset population that may be debilitating even after the treatment of Lyme disease. These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment.

Ultimately, it comes down to the IDSA (Infectious Diseases Society of America) arguing against chronic Lyme but in favor of post-Lyme disease syndromes, while the ILADS (International Lyme and Associated Diseases Society) believes chronic Lyme exists.

Regardless, the lingering effects of Lyme can be debilitating. This may be as a result of systemic inflammation (8). Systemic inflammation and its symptoms can be improved significantly with dietary and other lifestyle modifications.

But to throw one more wrench in the mix, the CDC recommends that physicians look beyond Lyme for other possible diagnoses before diagnosing someone with chronic Lyme disease (9).

Prevention is key to helping stem Lyme disease. If this is not possible, treating prophylactically when pulling off a tick is an important step. Contact your physician as soon as you notice a tick. If you have a bulls-eye rash and it is early, then treatment for two to three weeks needs to be started right away. If it is prolonged and disseminated, then treatment should be for approximately three to four weeks with antibiotics. If it has affected the central nervous system, then IV antibiotics could be needed.

References:

(1) Pediatrics. 1985;75(6):997. (2) nlm.nih.gov. (3) cdc.gov. (4) Clin Infect Dis. 2008;47(2):188. (5) uptodate.com. (6) MMWR. 2014;63(43):982-983. (7) Expert Rev Anti Infect Ther. 2011;9(7):787-797. (8) J Infect Dis. 2009;199(9:1379-1388). (9) JAMA Intern Med. online Nov. 3, 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.  

Stock photo
Toenail fungus can have medical implications

By David Dunaief, M.D.

Dr. David Dunaief

Summer is almost here, and millions of Americans are beginning to expose their toes. Some are more self-conscious about it because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is also an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat, although it affects approximately 8 percent of the population (2). The risk factors are unclear but may relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected (3).

Many organisms can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A KOH (potassium hydroxide) preparation can be used to differentiate them. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of psoriasis.

When considering treatment, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Oral antifungals

There are several oral antifungal options, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These tend to have the greatest success rate, but the disadvantages are their side effects. In a small but randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of toenail fungus with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration. Patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with the 24-week group experiencing better results.

The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine.

Another approach to reducing side effects is to give oral antifungals in a pulsed fashion. In an RCT, fluconazole 150 or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, it takes approximately a year of daily use, and its efficacy is not as great as oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In one trial, ciclopirox had to be applied daily for 48 weeks in patients with mild to moderate levels of fungus.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if they are effective.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (10). Partial improvement occurred in the toenails of 10 patients. The gel was applied daily for 48 weeks. The advantages are low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and a lower efficacy when compared to oral antifungals.

None of the treatments are perfect. Oral medications tend to be the most efficacious but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance.

If you decide on this approach, discuss it with your doctor; and do appropriate precautionary tests on a regular basis, such as liver enzyme monitoring with terbinafine. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better choice. No matter what, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196; Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) J Am Board Fam Med. 2011;24:69–74.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

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

Let’s look at the evidence.

Does exercise overcome inactivity?

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

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

Worse than obesity?

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

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

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

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

References:

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

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

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

By David Dunaief, M.D.

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

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

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

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

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

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

Myths versus realities

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

Medications

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

What about supplements?

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

Soy impact

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

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

Weight loss

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

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

Coffee

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

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

References:

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

Over 27 million people in the U.S. suffer from osteoarthritis (OA) (1). Osteoarthritis is insidious, developing over a long period of time. By nature, it is chronic. It is also a top cause of disability (2). What can we do about it?

It turns out that OA is not just caused by friction or age-related mechanical breakdown, but rather by a multitude of factors. These include friction, but also local inflammation, genes and metabolic processes at the cellular level (3). This means that we may be able to prevent and treat it better than we thought by using exercise, diet, medication, injections and possibly even supplements. Let’s look at some of the research.

How can exercise be beneficial?

In an older study, results showed that even a small 10-pound weight loss could result in an impressive 50 percent reduction of symptomatic knee OA over a 10-year period (4).

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

In the Multicenter Osteoarthritis Study (MOST), results showed that walking may indeed be useful to prevent functional decline (5). The patients in this study were a mean age of 67 and were obese, with a mean body mass index (BMI) of 31 kg/m2, and either had or were at risk for knee arthritis. In fact, the most interesting part of this study was that the researchers quantified the amount of walking needed to see a positive effect.

The least amount of walking to see a benefit was between 3,250 and 3,750 steps per day, measured by an ankle pedometer. The best results were seen in those walking more than 6,000 steps per day, a relatively modest amount. This was random, unstructured exercise. In addition, for every 1,000 extra steps per day, there was a 16 to 18 percent reduced risk of functional decline two years later.

Acetaminophen may not live up to its popularity

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

Although acetaminophen doesn’t have anti-inflammatory properties, it does have analgesic properties. However, in a meta-analysis (involving 137 studies), acetaminophen did not reduce pain for OA patients (7).

In this study, all other oral treatments were significantly better than acetaminophen, including diclofenac, naproxen and ibuprofen, as well as intra-articular (in the joint) injectables, such as hyaluronic acid and corticosteroids. The exception was an oral Cox-2 inhibitor, celecoxib, which was only marginally better.

What about NSAIDs?

NSAIDs (nonsteroidal anti-inflammatory drugs) help to reduce inflammation, by definition. However, they have side effects that may include gastrointestinal bleed, and they have a black box warning for heart attacks. Risk tends to escalate with a rise in dose. Interestingly, a newer formulation of diclofenac (Zorvolex) uses submicron particles, which are roughly 20 times smaller than the older version. This allows it to dissolve faster, so it requires a lower dosage.

The approved dosage for OA treatment is 35 mg, three times a day. In a 602-patient, one-year duration, open-label randomized controlled trial (RCT), the newer formulation of diclofenac demonstrated improvement in pain, functionality and quality of life (7). The adverse effects, or side effects, were similar to the placebo. The only caveat is that there was a high dropout rate in the treatment group; only 40 percent completed the trial when they were dosed three times daily.

Don’t forget about glucosamine and chondroitin

Study results for this supplement combination or its individual components for the treatment of OA have been mixed. In a double-blind RCT, the combination supplement improved joint space, narrowing and reducing the pain of knee OA over two years. However, pain was reduced no more than was seen in the placebo group (8).

In a Cochrane meta-analysis review study of 43 RCTs, results showed that chondroitin, with or without glucosamine, reduced the symptom of pain modestly compared to placebo in short-term studies (9). Yet, the researchers stipulate that most of the studies were of low quality.

So, think twice before reaching for the Tylenol. If you are having symptomatic OA pain, NSAIDs such as diclofenac may be a better choice, especially with SoluMatrix fine-particle technology that uses a lower dose, hopefully meaning fewer side effects.

Even though results are mixed, there is no significant downside to giving glucosamine-chondroitin supplements a chance. However, if it does not work after 12 weeks, it is unlikely to have a significant effect. Also, try increasing your walking step count gradually; this could reduce your risk of functional decline. And above all else, if you need to lose weight and do, you will reduce your risk of OA significantly.

References:

(1) Arthritis Rheum. 2008;58:26-35. (2) Popul Health Metr. 2006;4:11. (3) Lancet. 1997;350(9076):503. (4) Ann Intern Med.1992;116:535-539. (5) Arthritis Care Res (Hoboken). 2014;66(9):1328-1336. (6) Ann Intern Med. 2015;162:46-54. (7) ACR 2014 Annual Meeting: Abstract 249. (8) Ann Rheum Dis. Online Jan 6, 2014. (9) Cochrane Database Syst Rev. 2015 Jan 28;1:CD005614.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

Cardiovascular events including heart attacks 

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

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

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

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

Impact on life expectancy 

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

Diabetes and obesity risk

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

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

References:

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

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

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Medication guidelines have changed with recent studies

By David Dunaief, M.D.

Dr. David Dunaief

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

Medications with beneficial effects

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

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

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

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

Medication combination: negative impact

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

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

Aspirin: low dose vs. high dose

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

Lifestyle modifications

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

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

Fiber’s important role

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

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

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

References:

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

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

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Improving RHR can improve your healthy life span 

By David Dunaief, M.D.

Dr. David Dunaief

What does our heart rate, or pulse, tell us beyond the obvious fact that we are alive?

Our “normal” resting heart rate is between 60 to 100 beats per minute (bpm). A resting heart rate (RHR) above 100 bpm is referred to as tachycardia, or a racing heartbeat, and it has potentially serious consequences. 

However, even normal RHRs can be stratified to identify risks for diseases. What I mean is that, even in the normal range, as your resting heart rate increases, so do your potential risks. Actually, resting heart rate below approximately 70 bpm may be ideal.

Resting heart rate’s importance should not be underestimated. In fact, it may play a role in longevity, heart disease — including heart failure, arrhythmias, heart attacks and sudden cardiac death — and even chronic kidney disease. The good news is that RHR is modifiable. Methods that may reduce your rate include medications for high blood pressure, such as beta blockers, and lifestyle modifications, including meditation, dietary changes and exercise.

Impact on life span

Reducing RHR may be an important component in living a longer, healthier lifestyle. In the Copenhagen Male Study, a prospective study that followed 2,798 participants for 16 years, results showed that those with higher resting heart rates had a greater risk of death (1). There was a linear relationship between the risk of death and increasing RHR. Those who had a resting heart rate above 90 bpm were at a threefold greater risk of death, compared to those who had a RHR at or below 50 bpm. RHR was inversely related to the amount of physical activity.

Thus, the authors concluded that a “healthy” person with higher RHR may still have a shorter life span, with all other factors being equal, such as physical activity and blood pressure.

In contrast with the previous study, the following one took a “glass is half-full” approach to longevity. The Jerusalem Longitudinal Cohort Study showed that elderly women and men who had a lower RHR lived the longest (2). There were more than 2,000 study participants, ranging from 70 to 90 years old.

Your resting heart rate can help identify
potential health problems as well as gauge your current heart health.
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Heart disease mortality

In the Nord-Trondelag Health Study, a prospective observational study, those who had a higher RHR at the end of the study than they did at the beginning of the study 10 years prior were more likely to die from heart disease (3). In other words, as the RHR increased from less than 70 bpm to over 85 bpm, there was a 90 percent greater risk of heart disease, compared to those who maintained a RHR of less than 70 throughout the two measurements. This study involved 30,000 participants who were healthy volunteers at least 20 years old.

Heart attacks

In the Women’s Health Initiative, results showed a 26 percent decrease in the risk of cardiovascular events in those postmenopausal women who had a RHR below 62 bpm, compared to those who had a RHR above 76 bpm (4). Interestingly, these results were even more substantial in the subgroup of women who were newly postmenopausal, ranging in age from 50 to 64.

Effect on kidney function

I have written many times about chronic kidney disease. An interesting follow-up is resting heart rate and its impact on kidney function. In the Atherosclerosis Risk in Communities Study, results showed that the most severe form of chronic kidney disease, end-stage renal disease, was 98 percent more likely to occur in those with the highest RHR, compared to those with the lowest (5). There were approximately 13,000 participants in the study, with a 16-year follow-up. The authors hypothesized that this negative effect on the kidney may be due to a loss of homeostasis in the autonomic (involuntary) nervous system, resulting in blood vessel dysfunction, such as increased inflammation and vasoconstriction (narrowing).

Can RHR be too low?

Is there a resting heart rate that is too low? Well, it depends on the context. If you are a marathoner or an athlete, then a RHR in the 40s may not be abnormal. For a healthy, physically active individual, it is not uncommon to have a resting heart rate in the 50s. However, if you are on medications that reduce your RHR and/or have a chronic disease, such as heart failure, it is probably not advisable to go much below 60 bpm. Always ask your doctor about the appropriate resting heart rate for your particular situation.

Thus, resting heart rate is an easy and inexpensive biomarker to potentially determine risk stratification for disease and to increase longevity, even for those in the normal range. By monitoring and modifying RHR, we can use it as a tool for primary disease prevention. 

References:

(1) Heart Journal 2013 Jun;99(12):882-887. (2) J Am Geriatr Soc. 2013;61(1):40-45. (3) JAMA 2011; 306:2579-2587. (4) BMJ. 2009 Feb 3;338:b219. (5) J Am Soc Nephrol. 2010 Sept;21(9):1560-1570.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

Obesity is continuously covered in the media. And rightly so. Its economic cost to the U.S. is massive: in 2016, the cost of chronic diseases for which being obese or overweight is a risk factor totaled over $480 billion in direct health care costs and $1.24 trillion in lost economic productivity (1). These startling numbers don’t even consider the human cost of these diseases.

Obesity and its effect on life span

It’s well-known that obesity could have an impact on development of other chronic diseases and decrease quality of life, but to what extent? A 2013 study indicated that almost as many as one in five deaths in the U.S. is associated with obesity (2).

In a computer modeling study, results showed that those who are obese may lose up to eight years, almost a decade, of their life span (3). But that is only part of the picture. The other, more compelling result is that patients who are very obese, defined as a BMI >35 kg/m², could lose almost two decades of healthy living. According to the researchers, this means you may have diseases such as diabetes and cardiovascular disease. However, even those patients who were obese and those who were overweight could have reductions in life span, up to six years and three years, respectively.

This study evaluated 3,992 adults between the ages of 20 and 79. The data was taken from an NHANES database from 2003 to 2010, which looked at participants who went on to develop diabetes and cardiovascular disease. Though this is not a clinical trial, and there is a need for more study, the results are eye-opening, with the youngest and very obese negatively impacted the most.

Cancer impact

Since it is very difficult to “cure” cancer, it is important to reduce modifiable risk factors. Obesity may be one of these contributing factors, although it is hotly debatable how much of an impact obesity has on cancer development.  The American Society of Clinical Oncologists (ASCO), in a position paper, supported the idea that it is important to treat obesity in the fight against cancer (4). The authors indicate obesity may make the prognosis worse, may hinder the delivery of therapies to treat cancer, and may increase the risk of malignancy.

Also, possibly reinforcing ASCO’s stance, a study suggested that upward of a half-million cases of cancer worldwide were related to being overweight or obese, with the overwhelming concentration in North America and Europe (5).

Possible solutions

A potential counterweight to both the reductions in life quality and life expectancy may be a Mediterranean-type diet. In a published analysis of the Nurses’ Health Study, results show that the Mediterranean diet helped slow shortening of the telomeres (6). Repeat sequences of DNA found at the end of chromosomes, telomeres, shorten with age; the shorter the telomere, the shorter life expectancy.

Thus, the Mediterranean-type diet may decrease occurrence of chronic diseases, increase life span and decrease premature mortality — countering the effects of obesity. In fact, it may help treat obesity, though this was not mentioned in the study. Interestingly, the greater the adherence to the diet, rated on a scale of 0 to 9, the better the effect. Those who had an increase in adherence by three points saw a corresponding decrease in telomere aging by 4.5 years. There were 4,676 middle-aged women involved in this analysis. The researchers believe that the anti-inflammatory and antioxidant effects could be responsible for the diet’s effects.

According to an accompanying editorial, no individual component of the diet was identified as having beneficial effects by itself, so it may be the diet as a whole that is important (7).

Short-term solutions

There are easy-to-use distraction tactics that involve physical and mental techniques to reduce food cravings. These include tapping your foot on the floor, staring at a blank wall and alternating tapping your index finger against your forehead and your ear (8). The forehead and ear tapping technique was most effective, although probably most embarrassing in public. Among mental techniques, seeing pictures of foods that were unhealthy and focusing on their long-term detriments to health had the most impact (9). These short-term distractors were done for 30 seconds at a time. The results showed that they decreased food cravings in obese patients.

Exercise impact

I have written that exercise does not lead to fat percentage loss in adults. The results are different for adolescents, though. In a randomized controlled trial, results show that those in a resistance training group and those in a combined resistance and aerobic training group had significantly greater percentages of fat loss compared to a control group (10).

Interestingly, the aerobic group alone did not show a significant change in fat percent versus the control. There were 304 study participants, ages 14 to 18, followed for a six-month duration, and results were measured with MRI. The reason that resistance training was effective may have to do with an increase in muscle mass rather than a decrease in actual fat.

Obesity can have devastating effects, from potentially inducing cancer or worsening it, to shortening life expectancy and substantially decreasing quality of life. Fortunately, there may be ways to help treat obesity with specific lifestyle modifications. The Mediterranean diet as a whole may be an effective step toward decreasing the burden of obesity and reducing its complications. Kids, teenagers specifically, should be encouraged to do some resistance training. As we mentioned, there are simple techniques that may help reduce short-term food cravings.

References:

(1) “America’s Obesity Crisis,” Milken Institute. October, 2018. (2) Am J Public Health. 2013;103:1895-1901. (3) The Lancet Diabetes & Endocrinology, online Dec. 5, 2014. (4) J Clin Oncol. 2014;32(31):3568-3574. (5) The Lancet Oncology. online Nov. 26, 2014. (6) BMJ. online Dec. 2, 2014. (7) BMJ 2014;349:g6843. (8) Obesity Week 2014 abstract T-2658-P. (9) Obesity Week 2014 abstract T-3023-OR. (10) JAMA Pediatr. 2014;168(11):1006-1014.

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

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