Medical Compass

There are serious side effects of NSAIDs and Tylenol

Dr. David Dunaief

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

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

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

NSAIDs: The statistics

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

NSAIDs: Studies demonstrating adverse side effects

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

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

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

Is acetaminophen the answer?

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

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

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

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

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

References: 

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

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

Prevention is the way to go

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

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

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

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

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

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

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

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

References: 

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

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

Treating external hemorrhoids

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

Treating internal hemorrhoids

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

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

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

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

How to prevent hemorrhoids

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

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

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

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

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

References:

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

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

A nutrient-dense, plant-based diet appears to prevent and help manage diseases that can affect vision including cataracts. Stock photo
Diet can have a significant impact on cataract risk

By David Dunaief, M.D.

Dr. David Dunaief

Cataracts affect a substantial portion of the U.S. population. In fact, 24.4 million people in the U.S. over the age of 40 are currently afflicted, and this number is expected to increase approximately 58 percent by the year 2030 — only 12 years from now — according to estimates by the National Eye Institute (1).

Cataracts are defined as an opacity or cloudiness of the lens in the eye, which decreases vision over time, as it progresses. It’s very common for both eyes to be affected. We often think of cataracts as a symptom of age, but we can take an active role in preventing them.

There are enumerable modifiable risk factors including diet; smoking; sunlight exposure; chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity. I am going to discuss the dietary factor.

Prevention

In a prospective (forward-looking) study, diet was shown to have substantial effect on the risk reduction for cataracts (2). This study was the United Kingdom group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

There was an inverse relationship between the amount of meat consumed and cataract risk. In other words, those who ate a great amount of meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork. These results followed what is termed a dose-response curve. 

Compared to high meat eaters, every other group demonstrated a significant risk reduction as you progressed along a spectrum that included low meat eaters (15 percent reduction), fish eaters (21 percent reduction), vegetarians (30 percent reduction) and finally vegans (40 percent reduction). 

There really was not that much difference between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. Thus, you don’t have to become a vegan to see an effect.

In my clinical experience, I’ve also had several patients experience reversal of their cataracts after they transitioned to a nutrient-dense, plant-based diet. I didn’t think this was possible, but anecdotally, this is a very positive outcome and was confirmed by their ophthalmologists (eye doctors).

Mechanism of action

Oxidative stress is one of the major contributors to the development of cataracts. In a review article that looked at 70 different trials for the development of cataract and /or maculopathies, such as age-related macular degeneration, the authors concluded antioxidants, which are micronutrients found in foods, play an integral part in prevention (3). 

The authors go on to say that a diet rich in fruits and vegetables, as well as lifestyle modification with cessation of smoking and treatment of obesity at an early age, help to reduce the risk of cataracts. Thus, you are never too young or too old to take steps to prevent cataracts.

How do you treat cataracts?

The only effective way to treat cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens. This is done as an outpatient procedure and usually takes approximately 30 minutes. Fortunately, there is a very high success rate for this surgery. So why is it important to avoid cataracts if surgery is able to remedy the situation?

Potential consequences of surgery

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage age-related macular degeneration (AMD) after cataract surgery (4). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients. 

It has been hypothesized that the surgery may induce inflammatory changes and the development of leaky blood vessels in the retina of the eye. However, because this meta-analysis was based on observational studies, it is not clear whether undiagnosed AMD may have existed prior to the cataract surgery, since they have similar underlying causes related to oxida tive stress.

Therefore, if you can reduce the risk of cataracts through diet and other lifestyle modifications, plus avoid the potential consequences of cataract surgery, all while reducing the risk of chronic diseases, why not choose the win-win scenario?

References:

1. nei.nih.gov. 2. Am J Clin Nutr. 2011 May; 93(5): 1128-1135. 3. Exp Eye Res. 2007; 84: 229-245. 4. Ophthalmology. 2003; 110(10): 1960. 

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

The effects of high sodium are insidious

By David Dunaief, M.D.

Dr. David Dunaief

By now, most of us have been hit over the head with the fact that too much salt in our diets is unhealthy. Still, we respond with “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.” Unfortunately, these are myths. All of us should be concerned about salt or, more specifically, our sodium intake.

Excessive sodium in the diet does increase the risk of high blood pressure (hypertension); the consequences are stroke or heart disease. Approximately 90 percent of Americans consume too much sodium (1).

Now comes the interesting part. Sodium has a nefarious effect on the kidneys. In the Nurses Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it may be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

Excessive sodium in one’s diet can increase the risk of high blood pressure, which can lead to a stroke or heart disease. Stock photo

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

If the salt shaker is not the problem, what is? Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of not being able to get her rings off.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this goal. Excess sodium causes the body to retain fluids. 

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Is sea salt better than table salt? High amounts of salt are harmful, and the type is not as important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly salty, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org.

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.

A diet high in fiber may help decrease the risk of heart disease, obesity and diabetes and has been linked to a lower incidence of some types of cancer. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Many people worry about getting enough protein, when they really should be concerned about getting enough fiber. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases in the way that studies illustrate with fiber. 

As I mentioned in my previous article, Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily. 

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber rich.

Fiber has very powerful effects on our overall health. A very large prospective cohort study showed that fiber may increase longevity by decreasing mortality from cardiovascular disease, respiratory diseases and other infectious diseases (1). Over a nine-year period, those who ate the most fiber, in the highest quintile group, were 22 percent less likely to die than those in lowest group. Patients who consumed the most fiber also saw a significant decrease in mortality from cardiovascular disease, respiratory diseases and infectious diseases. The authors of the study believe that it may be the anti-inflammatory and anti-oxidant effects of whole grains that are responsible for the positive results. 

Along the same lines of the respiratory findings, we see benefit with prevention of chronic obstructive pulmonary disease (COPD) with fiber in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities study (2). The specific source of fiber was important. Fruit had the most significant effect on preventing COPD, with a 28 percent reduction in risk. Cereal fiber also had a substantial effect but not as great.

Does the type of fiber make a difference? One of the complexities is that there are a number of different classifications of fiber, from soluble to viscous to fermentable. Within each of the types, there are subtypes of fiber. Not all fiber sources are equal. Some are more effective in preventing or treating certain diseases. Take, for instance, a February 2004 irritable bowel syndrome (IBS) study (3). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Fiber also has powerful effects on breast cancer treatment. In a study published in the American Journal of Clinical Nutrition, soluble fiber had a significant impact on breast cancer risk reduction in estrogen negative women (4). Most beneficial studies for breast cancer have shown results in estrogen receptor positive women. This is one of the few studies that has illustrated significant results in estrogen receptor negative women. 

The list of chronic diseases and disorders that fiber prevents and/or treats also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease dependent. However, if you are trying to prevent chronic diseases in general, I would recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased energy levels. Certainly, while protein is important, each time you sit down at a meal, rather than asking how much protein is in it, you now know to ask how much fiber is in it. 

References:

(1) Arch Intern Med. 2011;171(12):1061-1068. (2) Amer J Epidemiology 2008;167(5):570-578. (3) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (4) Amer J Clinical Nutrition 2009;90(3):664–671. 

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.

Preventing diabetes, cancer and stroke

By David Dunaief, M.D.

Dr. David Dunaief

What better way than a season centered around eating al fresco to kick-start you on the path to preventing chronic diseases? In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are foods commonly found at barbecues and picnic meals. Therefore, I think it is only fair to talk about healthier alternatives and the evidence-based medicine that supports their benefits.

The Mediterranean-style diet is the key to success. It is composed of thousands of beneficial nutrients that interact with each other in a synergistic way. This particular diet, as I have mentioned in previous articles, includes fish, green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of olive oil. We all want to be healthier, but doesn’t healthy mean tasteless? Not necessarily.

At a memorable family barbecue, we had a bevy of choices that were absolutely succulent. These included a three-bean salad, mandarin orange salad with raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon filets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable and scallop shish kebobs and a large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence.

Cancer studies

Fruits and vegetables may help prevent pancreatic cancer. This is very important, since by the time there are symptoms, the cancer has spread to other organs and the patient usually has less than 2.7 years to live (1). Five-year survival is only 5 percent (2). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and noncitrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (3). Interestingly, cooked vegetables, not just raw ones, had a substantial effect. 

Garlic plays an important role in reducing the risk of colon cancer. In the IOWA Women’s Health Study, a large prospective (forward-looking) trial involving 41,837 women, there was a 32 percent reduction in risk of colon cancer for the highest intake of garlic compared to the lowest. Vegetables also showed a statistically significant reduction in the disease as well (4). Many of my patients find that fresh garlic provides a wonderful flavor when cooking vegetables.

Diabetes studies — treatment and prevention

Fish plays an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of intake of fish and seafood had a substanttial decrease in risk of Type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood in potentially preventing the disease. Therefore, there is nothing wrong with shrimp on the “barbie” to help protect you from developing diabetes. 

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial (the gold standard of studies), mixed nuts led to a substantial reduction of hemoglobin A1c, a very important biomarker for sugar levels for the past three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease. The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke 

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial. Though these are promising results, I would caution use no more than one tablespoon of olive oil per day, since there are 120 calories in a tablespoon. 

It is not difficult to substitute the valuable Mediterranean-style diet for processed meats or at least add them to the selection. This plant-based diet offers a tremendous number of protective elements in the prevention of many chronic diseases. So this Independence Day and beyond, plan to have on hand some mouth-watering healthy choices.

» A staple of the Mediterranean pantry, beans are a healthy, versatile and super affordable ingredient. Rich in antioxidants, fiber, B vitamins and iron, they are a hearty great alternative to high-fat proteins. Serve guests the following three-bean salad as a side dish at your next summer barbecue or picnic. 

Three-Bean Salad

YIELD: Makes 10 servings

INGREDIENTS:

1 15-ounce can of black beans

1 15-ounce can of red kidney beans

1 15-oounce can of cannellini beans

1 yellow bell pepper, chopped

½ red onion, finely chopped

¼ cup olive oil

2 tablespoons red wine vinegar or to taste

1 clove garlic, minced

1 small bunch cilantro, basil or parsley, chopped

¼ cup dill pickle, diced

¼ cup celery, chopped

Salt and pepper to taste

DIRECTIONS: 

Wash and drain the beans. Transfer to large bowl. Add remaining ingredients, toss well and refrigerate for a few hours before serving.

References:

(1) Nature. 2010;467:1114-1117. (2) Epidemiol Prev Anno 2007;31(Suppl 1). (3) Cancer Causes Control. 2010;21:493-500. (4) Am J Epidemiol. 1994 Jan 1;139(1):1-15. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-1711. (7) Neurology. 2011 Aug 2;77(5):418-425. 

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

Lack of exercise is the dominant risk factor for heart attacks. Stock photo
Over the age of 30, inactivity creates the greatest risk

By David Dunaief, M.D.

Dr. David Dunaief

In last week’s article, I wrote about unusual symptoms that may indicate a myocardial infarction (heart attack) and the importance of knowing these atypical major symptoms beyond chest pain. This is not an easy task. I thought a good follow-up to that article would be one that focused on preventable risk factors.

The good news, as I mentioned previously, is that we have made great strides in reducing mortality from heart attacks. When we compare cardiovascular disease — heart disease and stroke — mortality rates from 1975 to the present, there is a substantial decline of approximately one-quarter. However, if we look at these rates since 1990, the rate of decline has slowed (1).

Plus, one in 10 visits to the emergency room are related to potential heart attack symptoms. Luckily, only 10 to 20 percent of these patients actually are having a heart attack (2). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. The obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. Less obvious risk factors include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, also may help allay the risks.

Let’s look at the evidence.

Obesity

On a board exam in medicine, if smoking is one of the choices with disease risk, you can’t go wrong by choosing it. Well, it appears that the same axiom holds true for obesity. But how substantial a risk factor is obesity? 

In the Copenhagen General Population Study, results showed an increased heart attack risk in obese (BMI >30 kg/m²) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m²) (3). The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Since this was an observational trial, we can only make an association, but if it is true, then there may not be such a thing as a “metabolically healthy” obese patient. Therefore, if you are obese, it is really important to lose weight.

Sedentary lifestyle

If obesity were not enough of a wake-up call, let’s look at another aspect of lifestyle: the impact of being sedentary. An observational study found that activity levels had a surprisingly high impact on heart disease risk (4). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect on women’s heart disease risk. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over the age of 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported and not necessarily measured in a doctor’s office, it may have been underestimated as a risk factor for heart disease. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Gout

When we think of gout, we relate it to kidney stones. But gout increases the risk of heart attacks by 82 percent, according to an observational study (6). Gout tends to affect patients more when they are older, but the risk of heart attack with gout is greater in those who are younger, ages 45 to 69, than in those over 70. What can we do to reduce these risk factors?

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (7).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is the fact that those who increased their fiber after the cardiovascular event had a 31 percent reduction in mortality risk. In this analysis, it seemed that more of the benefit came from fiber found in cereal. The most intriguing part of the study was the dose response. For every 10-g increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events such as heart attacks (8).

Osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? Well, in a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack. (5) Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References:

(1) Heart. 1998;81(4):380. (2) JAMA Intern Med. 2014;174(2):241-249. (3) JAMA Intern Med. 2014;174(1):15-22. (4) Br J Sports Med. 2014, May 8. (5) Presented Research: World Congress on OA, 2014. (6) Rheumatology (Oxford). 2013 Dec;52(12):2251-2259. (7) BMJ. 2014;348:g2659.  (8) N Engl J Med. 2000;343(1):16.

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

A heart attack does not always have obvious symptoms. Stock photo
Chest pain is only one indicator

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is the most common chronic disease in America. When we refer to heart disease, it is an umbrella term; heart attacks are one component. Fortunately, the incidence of heart attacks has decreased over the last several decades, as have deaths from heart attacks. However, there are still 720,000 heart attacks every year, and more than two-thirds are first heart attacks (1).

How can we further improve these statistics and save more lives? We can do this by increasing awareness and education about heart attacks. It is a multifaceted approach: recognizing the symptoms and knowing what to do if you think you’re having a heart attack.

If you think someone is having a heart attack, call 911 as quickly as possible and have the patient chew an adult aspirin (325 mg) or four baby aspirins. Note that the Food and Drug Administration does not recommend aspirin for primary prevention of a heart attack. However, the use of aspirin here is for treatment of a potential heart attack, not prevention. It is also very important to know the risk factors and how to potentially modify them.

Heart attack symptoms

The main symptom is chest pain, which most people don’t have trouble recognizing. However, there are a number of other, more subtle, symptoms such as discomfort or pain in the jaw, neck, back, arms and epigastric, or upper abdominal, areas. Others include nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate). One problem is that less than one-third of people know these other major symptoms (2). About 10 percent of patients present with atypical symptoms — without chest pain — according to one study (3).

It is not only difficult for the patient but also for the medical community, especially the emergency room, to determine who is having a heart attack. Fortunately, approximately 80 to 85 percent of chest pain sufferers are not having a heart attack. More likely, they have indigestion, reflux or other non-life-threatening ailments.

There has been a raging debate about whether men and women have different symptoms when it comes to heart attacks. Several studies speak to this topic. Let’s look at the evidence.

Men vs. women

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish prospective (forward-looking) study, after having a heart attack, a significantly greater number of women died in hospital or near-term when compared to men. The women received reperfusion therapy, artery opening treatment that consisted of medications or invasive procedures less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram; they both had what we call ST elevations. This was a study involving approximately 54,000 heart attack patients, with one-third of them being women.

One theory about why women are treated less aggressively when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. Women’s symptoms may include pain in the lower portion of the chest or upper portion of the abdomen and may have significantly less severe pain that could radiate or spread to the arms. But, is this true? Not according to several studies.

In one observational study, results showed that, though there were some subtle differences in chest pain, on the whole, when men and women presented with this main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: The duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The study included approximately 2,500 patients, all of whom had chest pain. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. This was a conspicuous weakness of an otherwise mostly solid study, since age and previous heart attack history are important factors.

Therefore, I thought it apt to present another observational study with a younger population, where there was no significant difference in age; the median age of both men and women was 49. In this GENESIS-PRAXY study, results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings (non-ST elevations), significantly more were women than men. Those who did not have chest pain symptoms may have had some of the following symptoms: back discomfort, weakness, discomfort or pain in the throat, neck, right arm and/or shoulder, flushing, nausea, vomiting and headache.

If the patients did not have chest pain, regardless of sex, the symptoms were, unfortunately, diffuse and nonspecific. The researchers were looking at acute coronary syndrome, which encompasses heart attacks. In this case, independent risk factors for disease not related to chest pain included both tachycardia (rapid heart rate) and being female. The authors concluded that there need to be better ways to calibrate non-chest pain symptoms.Some studies imply that as much as 35 percent of patients do not present with chest pain as their primary complaint (7).

Let’s summarize

So what have we learned about heart attack symptoms? The simplest lessons are that most patients have chest pain, and that both men and women have similar types of chest pain. However, this is where the simplicity stops and the complexity begins. The percentage of patients who present without chest pain seems to vary significantly depending on the study — ranging from less than 10 percent to 35 percent.

Therefore, it is even difficult to quantify the number of non-chest pain heart attacks. This is why it is even more important to be aware of the symptoms. Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. When it comes to heart attacks, suspicion should be based on the same symptoms for both sexes. Therefore, know the symptoms, for it may be your life or a loved one’s that depends on it.

References:

(1) Circulation. 2014;128. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA. 2012;307:813-822.

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