Medical Compass

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It is now mid-January, and most of us have made a New Year’s resolution. You’ve taken the first step, but how do you increase the “stickiness factor,” a term used by Malcolm Gladwell in his book, “The Tipping Point: How Little Things Make a Big Difference.”

Setting a goal that is simple and singular helps.  We often overdo it by focusing on multiple resolutions on a host of topics, like being organized, working more efficiently and improving health. While these are all admirable, multiple large goals diminish your chances of success. Instead, your goal might be to improve health by losing weight and reversing disease.

Changing habits is always hard. There are some things that you can do to make it easier, though.

Environment

Your environment is very important.  According to Dr. David Katz,  director, Yale-Griffin Prevention Research Center, it is not as much about willpower as it is about your environment. He wrote about this subject in the Huffington Post on Jan. 4 in response to Tara Parker-Pope’s Jan. 1, New York Times Magazine article about weight loss.

Willpower, Dr. Katz writes, is analogous to holding your breath underwater — it is only effective for a short time frame. Thus, he suggests laying the groundwork by altering your environment to make it conducive to attaining your goals. Recognizing your obstacles and making plans to avoid or overcome them reduces stress and strain on your willpower.

According to a recent study, people with the most self-control utilize the least amount of willpower, since they take a proactive role in minimizing temptation (J Pers Soc Psychol. 2012;102:22-31). Start by changing the environment in your kitchen. I touched on the importance of environment in my Nov. 25, 2010, article.

Support is another critical element.  It can come from within, but it is best when reinforced by family members, friends and co-workers. In my practice, I find that patients who are most successful with lifestyle changes are those where household members are encouraging or, even better, when they participate in at least some portion of the intervention, such as eating the same meals.

Automaticity: Forming new habits

When does a change become a new habit? The rule of thumb used to be it takes approximately three weeks. However, the results of a study at the University of London showed that the time to form a habit, such as exercising, ranged from 18 days to 254 days (European Journal of Social Psychology, 40: 998–1009). The good news is that, though there was a wide variance, the average time to reach this automaticity was 66 days, or about two months.

Lifestyle modification:  Choosing a diet

U.S. News and World Report released its second annual ranking of diets last week. The panel included 22 weight-loss and nutrition experts. Three of the diets highlighted include the DASH (Dietary Approaches to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. All three diets were ranked in the top five for heart health. The DASH diet was ranked the No. 1 overall diet, and the Mediterranean diet was ranked No. 3. Both the Ornish and the DASH diets ranked within the top three for diabetes.

What do these diets have in common? They focus on nutrient-dense foods. In fact, the lifestyle modifications that I recommend are based on a combination of these three diets and the evidence-based medicine that supports them.

For instance, in a randomized crossover trial, which means patients after a prescribed time can switch to the more effective group, showed that the DASH diet is not just for patients with high blood pressure. The DASH diet was more efficacious than the control diet in terms of diabetes (decreased hemoglobin A1C 1.7 percent and 0.2 percent, respectively), weight loss (5 kg/11 lbs. vs. 2 kg/4.4 lbs.), as well as in HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (Diabetes Care. 2011;34:55-57).

Interestingly, patients still lost weight, although caloric intake and the percentages of fats, protein and carbohydrates were the same between the DASH and control diets. However, the DASH diet used different sources of these macronutrients. The DASH diet also contained foods with higher amounts of fiber, calcium and potassium and lower sodium.
Therefore, diets high in nutrient-dense foods may be an effective way to lose weight while treating and preventing disease.

Hopefully, I have inspired you to achieve your New Year’s resolutions. And one more tip: Don’t trip over the present looking to the future. In other words, take it day by day, rather than obsessing on the larger picture. Health and weight loss can — and should — go together.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Research shows TIA increases the risk of a heart attack by 200 percent

I recently helped manage a patient who had been diagnosed with a TIA: transient ischemic attack. The patient’s only symptom was double vision. A TIA is sometimes referred to as a ministroke. This is a disservice, since it makes a TIA sound like it should be taken lightly.

Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot that needs to be taken very seriously. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (Stroke. Apr 2005;36(4):720-3; Neurology. May 13 2003;60(9):1429-34). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. TIA incidence increases with age (Stroke. Apr 2005;36(4):720-3).

What is a TIA? The definition has changed from one purely based on time (less than 24 hours) to differentiate it from a stroke, to one that is tissue based. It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia — low blood flow in the back of the eye — without evidence of acute infarction (tissue death) (N Engl J Med. Nov 21 2002;347(21):1713-6).

It has been shown that tissue death and/or lesions can occur on diffusion-weighted MRI. In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, with difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Why take a TIA seriously if its debilitating effects may be temporary? TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death.

Stroke

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (Neurology 2011 Sep 27; 77:1222). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (Lancet Neurol. Dec 2007;6(12):1063-72).

Even worse, the probability that a patient will experience a stroke reaches approximately 30 percent after five years (Albers et al., 1999).

Heart attack

In a recent epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (Stroke. 2011; 42: 935-940). These are patients without known heart disease.

Interestingly, the risk of heart attacks was much higher in those under 60 years of age, and continued for years after the event. Just because you may have not had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack. Even patients taking statins to lower cholesterol were at higher risk of heart attack after a TIA.

Mortality

TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years, and by 20 percent after nine years, especially in those over age 65, according to a study published in Stroke online, Nov. 10.

The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort (particular group of patients) study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (Stroke. 2011 Jul;42(7):1857-61). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (JAMA. 2005 Mar 23;293(12):1435). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include the Mediterranean and DASH diet combination I elaborated on in my Dec. 22 article, “Stroke prevention is the best treatment.” Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

In researching this article, I realized that there are not many separate studies for TIA since they are usually clumped with stroke studies. This underscores its seriousness. If you or someone you know has a TIA, the patient needs to see a neurologist and a primary care physician and/or cardiologist immediately.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Intensive medical counseling effective; reimbursement now approved by Medicare

Over the last week, I have been stunned by the incredible number of ads for New Year’s resolution diets, including ones specifically targeting men. I would like to talk about what may and may not work when dealing with weight loss. Obesity has dramatically increased over the last 30 years and now has reached epidemic proportions according to the Centers for Disease Control. By the year 2030, half of the U.S. population is expected to be obese (The Lancet 2011;378:741-748).

Obesity is associated with many chronic diseases, including heart disease, stroke, cancer, diabetes and osteoarthritis and is a major contributor to death (Ann Intern Med 2003;139:933-949).

So, why not start the new year with a positive step in the right direction? One of the top New Year’s resolutions is to lose weight. We need to act on this, and Medicare has recently provided an incentive for both patients and physicians. What do I mean by this? Medicare has approved reimbursement for intensive management of obesity by primary care physicians.

What does this include, and what is meant by intensive? Patients who are deemed obese, defined as a BMI (body mass index) >30kg/m2 are eligible for a year’s worth of intensive obesity counseling. This breaks down as follows: weekly visits to the physician for the first month and then every other week for months two through six. If the patient has lost a modest 6.6 pounds, then counseling can continue on a monthly basis for months seven through 12. This is a substantial step forward in the battle of the bulge. I commend the current administration for its efforts.

What have studies shown?
In a recent randomized clinical trial — the gold standard of trial designs — called the Practice-based Opportunities for Weight Reduction study, those who underwent more intensive weight-loss counseling through primary care physicians’ offices saw significant reduction in weight that was, most importantly, maintained over a two-year period (N Engl J Med 2011; 365:1959-1968). The mean change in weight was a loss of 5.1 kg, or 11.2 pounds, in the intensive group compared to the control group (usual care) who lost 0.8 kg, or 1.8 pounds. These results were statistically significant.

In a meta-analysis ( a group of studies), there was a 6.6 pound greater weight loss in the intervention group than the control group over 12 to 18 months with a greater number of treatment sessions resulting in a greater amount of weight loss (Ann Intern Med 2011;155:434-437).

There have been a number of other studies showing substantial weight loss over two years with a high nutrient density diet; participants shed a mean of 53 pounds over that period (Altern Ther Health Med. 2008 May-Jun;14(3):48-53), but it was not a randomized control trial.

The U.S. Preventive Services Task Force has been recommending obesity counseling for patients. It found that it helped to improved blood pressure, cholesterol levels and glucose metabolism, among other things, with even modest weight loss.

Calorie restriction approach: the problem
There are many programs doctors can choose from to help patients. However not all programs are equal. Severe calorie restriction may work for the short term, but is not really a solution for the long term. Complications arise when hormones, such as leptin, ghrelin, peptide YY, glucose-like peptide 1 (GLP-1) and insulin, are thrown out of balance and the body strives to replace the weight that has been lost (N Engl J Med 2011; 365:1597-1604). The hormones, instead of suppressing appetite, actually create an environment ripe for regaining weight, setting up the patient for failure. I touched on the physiologic effects related to weight loss in an article on Oct. 21, 2010.

The importance of nutrient dense foods
It is not as much about calorie restriction as it is about nutrients from foods. Nutrient dense substances not only help with weight loss, but are very important for treatment and prevention of disease. Regardless of whether someone is obese or not, nutrient-dense diets, such as the Mediterranean-type diet and the DASH diet, have shown tremendous benefit in the treatment and prevention of chronic disease. There is even a potential association between micronutrient (nutrient dense) food deficiencies and obesity (Nutr Rev. 2009 Oct;67(10):559-72). Thus, it is about lifestyle modification rather than “dieting.”

This is just too great an opportunity not to be a participating patient. Intensive guidance by the medical community can help patients lose weight, if done right, for the long term. The prevailing thought in medicine is that private insurance companies will follow suit, which would be great news for those not eligible for Medicare.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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