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Diet

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By Leah S. Dunaief

Leah Dunaief

We seem to be living at a higher level of anxiety. Maybe not all of us. Somewhere there might be one or two souls who are still calmly oblivious to the world around us. Those are the ones who have turned off their televisions and radios, who don’t read newspapers and have put away their cellphones. But from conversations I have had, that’s not the rest of us. The rest of us are quietly, or not so quietly concerned.

What’s wrong? Let’s make a list. Better yet, let’s not. Instead, let’s think about how to cope.

One way to start is to divide what troubles us into two lists: those we can do something about and those we cannot. Then concentrate on the former. When confronted with hate, we can respond with kindness. We can listen rather than scream. We can do our tiny bit to help make our neighborhood a better place.

A psychotherapist I was interviewing recently told me she instructs her anxious clients to concentrate on their breathing, taking deep breaths for ten minutes to calm the body. The usual trio of eating, sleeping and exercising properly are critically important to maintain. Meditation, and even aromatherapy may also help. 

Specifically:

Exercise regularly. It’s good for both body and mind. One recent study revealed that “people with physically active lifestyles had about 60 percent lower risk of developing anxiety disorders,” according to healthline. This study was done over 21 years and followed 400,000 participants.

How does exercise work? For one, it provides a distraction from whatever is worrying. Also, getting the heart rate up changes brain chemistry, encouraging the secretion of anti-anxiety brain messengers like serotonin and gamma-aminobutyric acid (GABA). According to the American Psychological Association, “regular exercise leads to an enhancement of concentration and willpower, which can help certain anxiety symptoms.” 

Plus you feel good, especially when you stop. Walking is the simplest and perhaps most enjoyable way to exercise, particularly at this time of year, when it is not too hot nor too cold, and the changing colors of the foliage are a delight.

Eating a balanced diet, and eating it calmly, is important. Low blood sugar levels, dehydration and chemicals in processed foods, such as artificial flavorings, artificial coloring and preservatives can cause mood changes. A high-sugar diet can also have a negative reaction. So what should we eat? Fruits and vegetables, especially those leafy dark green ones rather than those high in starch, are ideal. After that, complex carbohydrates and beans, are a good source of nutrition. I happen to like fish, the white fleshy kind like sea bass, rather than lean meat, for animal protein. But remember, there is plenty of protein in veggies and beans.

Sleep is so important. A good night’s sleep leaves me feeling as if, the next day, I could “leap tall buildings at a single bound,” to borrow from the Superman tagline. Ah, but how to get a good night’s sleep? I am a good sleeper, and I will tell you what I do—most of the time.

I don’t watch television or use my computer or cellphone before going to bed. Something about that blue light wakes me up. I don’t even have those in my bedroom. I will sometimes read a bit, but not a page turner. My room is the coolest in the house, and I will frequently have the window open, even a tiny bit, in winter. I know that going to bed the same time each night is recommended, though I don’t always follow that advice. Also no alcohol before bedtime is also advised. It helps put me to sleep but I will be wide awake when the alcohol wears off in the middle of the night. And, I invested in a comfy down comforter years ago that, with its plushness, invites me into bed.

Better not to nap during the day, and that leaves me sufficiently tired by bedtime, especially if I have exercised. At least, it should. If it doesn’t, I will empty my thoughts onto a list, put the pad on the bedside table, then doze off.

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'I have seen very good results when treating patients who have eczema with dietary changes.- Dr. David Dunaief METRO photo
New treatments are evolving

By David Dunaief, M.D.

Dr. David Dunaief

If you have eczema, you’re familiar with its symptoms, which can include rashes, itching, pain and redness. What may not be as clear are its causes and potential implications.

Eczema is a chronic inflammatory process, and it’s likely caused by a combination of genetics and lifestyle choices (1).

While there is no cure, some treatments can ease symptoms and reduce flare-ups. These range from over-the-counter creams and lotions, antihistamines for itchiness, prescription steroid creams, oral steroids, and injectable biologics. Some sufferers use phototherapy for severe cases, but there’s not a lot of research suggesting this is effective. Interestingly, diet may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

How does diet affect eczema?

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (2).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet of those who were allergic, according to IgE testing, eczema improved significantly (3).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes many patients who suffer from some level of eczema. For example, a young adult had eczema mostly on his extremities. When we first met, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin improved significantly.

Do supplements help reduce eczema symptoms?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective. There are also some important concerns about them.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (4).

The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (5).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Are biologics a good alternative?

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (6). There are two currently approved by the FDA, dupilumab and tralokinumab.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like other monoclonal antibodies, they work by interfering with parts of your immune system. They suppress messengers of the white blood cells, called interleukins. This leaves a door open for side effects, like serious infections.

Does eczema affect bone health?

Several studies have examined the relationship between eczema and broken bones. One observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and a 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (7).

If you have both fatigue or insomnia in combination with eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that corticosteroids used in treatment could be one reason, in addition to chronic inflammation, which may also contribute to bone loss risk. 

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (8). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life. Supplements may not be the solution, at least not borage oil nor evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroids because of their long-term side effects. Diet adjustments appear to be very effective, at least at the anecdotal level.

References:

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) Allergy. 2010 Jun 1;65(6):758-765. (3) J Am Acad Dermatol. 2004;50(3):391-404. (4) Cochrane Database Syst Rev. 2013;4:CD004416. (5) mayoclinic.org (9) Medscape.com. (6) JAMA Dermatol. 2015;151(1):33-41. (7) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (8) nationaleczema.org.

Dr. David 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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We know better. So why can’t we do better?

By David Dunaief, M.D.

Dr. David Dunaief

We are continuously inundated with messages about the importance of including fruits and vegetables in our daily diets. In addition to fiber, they include critical nutrients and micronutrients that keep us healthy and reduce our risks of developing chronic diseases.

Despite this, according to a 2022 report by the Centers for Disease Control and Prevention (CDC), an average of 12.3 percent of U.S. adults met the daily requirements for fruit intake, and an even more abysmal 10 percent met vegetable intake recommendations (1). As you might expect, it follows that we are deficient in many key micronutrients (2).

Why do we care? Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients. 

Here’s a stunning statistic: more than 50 percent of American adults have a chronic disease, with 27 percent having more than one (3). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade and are currently at around 77 years old.

One indicator of nutrient intake that we can measure is carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. I measure these regularly, because they give me a sense of whether the patient might lack potentially disease-fighting nutrients. A high nutrient intake dietary approach can resolve the situation and increase both carotenoid and other critical nutrient levels.

Why focus on a high nutrient intake diet?

A high nutrient intake diet focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals — plant nutrients. Micronutrients are bioactive compounds found mostly in foods and in some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum of them is greater than their parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (4).

A 20 percent increase in diet scores, which indicated an improved quality of diet, was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent more than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large, prospective cohort study, where the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

How can diet improve your quality of life?

Quality of life is as important as longevity. Let’s examine some studies that consider the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (6). The authors attribute this effect, at least partially, to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. Each tablespoon of olive oil contains 120 calories, all of them fat. If you eat too much of even good fat, it can be counterproductive. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s.

In a case-control study that compared those with and without disease, high intake of antioxidants from food was associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), the leading cause of blindness in those 55 years or older (7). This was true even when participants had a genetic predisposition for the disease.

There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can improve our outcomes. With a focus on a high nutrient intake diet, we can improve life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. Morb Mortal Wkly Rep 2022;71:1–9. (2) cdc.gov/nutritionreport (3) cdc.gov. (4) N Engl J Med 2017; 377:143-153. (5) BMJ. 2009;338:b2337. (6) Neurology June 15, 2011. (7) Arch Ophthalmol. 2011;129(6):758-766.

Dr. David 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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Different dietary approaches may help modulate the immune system

By Dr. David Dunaief

Dr. David Dunaief

Autoimmune disease is when the body’s immune system attacks the organs, cells and tissues and causes chronic inflammation. However, this umbrella term refers to more than 80 different diseases (1). Some are familiar names, like type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, multiple sclerosis, and inflammatory bowel disease. Others, like Lambert-Eaton myasthenic syndrome and Cogan syndrome, are less well-known.

Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others. They disproportionately affect women, although men are also at risk.

Treating autoimmune diseases with meds

The primary treatment is immunosuppressives. In RA, for example, where there is swelling of joints bilaterally, a typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

However, there are several concerning factors with these drugs. First, the side-effect profiles are substantial. They includes risks of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning required by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

It is no surprise that suppressing the immune system would increase the likelihood of infections. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term clinical trials; however, many patients are prescribed these therapies for 20 or more years.

So, what other methods are available to treat autoimmune diseases? Medical nutrition therapy using bioactive compounds and supplementation are being studied. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

Managing inflammation with nutrition

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including c-reactive protein (CRP), and improvements in joint pain and other quality of life concerns.

Fish oil’s effects

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). A typical recommendation is to consume about 2 grams of EPA plus DHA to help regulate the immune system. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood-thinning effects.

Probiotic supplements

Approximately 70 percent of your immune system lives in your gut. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Increasing fiber intake

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and, potentially, autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high-nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects, treating and preventing autoimmune diseases.

References: 

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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

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Moderate exercise is better for weight maintenance than weight loss

By David Dunaief, M.D.

Dr. David Dunaief

It’s that time of year again, when exercise product commercials flood the airways. If you have “lose weight” on your list of 2022 resolutions, it’s helpful to consider what the research tells us about the relationship between exercise and weight loss.

Unfortunately, exercise without dietary changes may not actually help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance.

Ultimately, it may be more important to reconsider what you are eating than to succumb to the rationalization that you can eat with abandon and work it off later.

Don’t give up on exercise just yet, though. There is good news: Exercise does have benefits for a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.

Exercise may not result in weight loss

The well-known weight-loss paradigm is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration (12 weeks). All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise — or, in other words, a moderately intense pace. 

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Exercise and weight maintenance

However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Exercise and disease

Walking the dog several times a week is a good moderate exercise. METRO Photo

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 15 percent of adults in the United States, according to the Centers for Disease Control and Prevention (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3 to 5 (8). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact, and results were based on a dose-response curve. In other words, the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

Therefore, while there are many benefits to exercise, food choices will have a greater impact on our weight and body composition. 

However, exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

So, by all means, exercise, but also focus on consuming nutrient-dense foods instead of calorically dense foods that you may not be able to exercise away.

References:

(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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

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Much of our sodium comes from processed foods, including breads and sauces

By David Dunaief, M.D.

Dr. David Dunaief

When you hear someone tell you that you should lower your salt intake, how do you respond? Typically, I hear responses like, “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 rarely true. All of us should be concerned about salt or, more specifically, our sodium intake. Also, approximately 90 percent of Americans consume too much sodium (1).

Why do we care?

We most often hear that excessive sodium in our diets increases the risk of high blood pressure (hypertension), which has consequences like stroke and heart disease.

Now comes the interesting part. Sodium also 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 can 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.

How much is too much?

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.

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).

Where does sodium hide?

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 or ordering in 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 her clothes and rings being tight.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this. 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.

Breads and rolls are another hidden source. Most contain a decent amount of sodium. I have seen a single slice of whole wheat bread include up to 200 mg. of sodium.

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.

What about sea salt?

Are fancy sea salts better than table salt? High amounts of salt are harmful, and the type is not 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.

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

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Diet choices trump exercise for weight loss

By David Dunaief, M.D.

Dr. David Dunaief

To quash guilt about Thanksgiving meal indiscretions, many of us will resolve to exercise to burn off the calories from this seismic meal and the smaller, calorically dense aftershock meals, whether with a vigorous family football game or with a more modest walk.

Unfortunately, exercise without dietary changes may not actually help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance. Ultimately, it may be more important to reconsider what you are eating than to succumb to the rationalization that you can eat with abandon during the holidays and work it off later.

Don’t give up on exercise just yet, though. There is very good news: Exercise does have beneficial effects on a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.

Let’s look at the evidence.

Exercise for weight loss

The well-known weight-loss paradigm is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women (55) gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise — or, in other words, a moderately intense pace.

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study. This was a preliminary study, so no definitive conclusions can be made.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Exercise and weight maintenance

However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Exercise and disease

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 15 percent, or one in seven, adults in the United States, according to the Centers for Disease Control and Prevention (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3-5 (8). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact; results were based on a dose-response curve. In other words, the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

Therefore, while it is important to enjoy the holidays, remember that food choices will have the greatest impact on our weight and body composition. However, exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

So, by all means, exercise during the holidays, but also focus on more nutrient-dense foods. At a minimum, strike a balance rather than eating purely calorically dense foods. You won’t be able to exercise them away.

References:

(1) uptodate.com. (2) J Strength Cond Res. Online Oct. 28, 2014. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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

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Stock photo

By Matthew Kearns, DVM

I’ve always had trouble instituting New Year’s resolutions. Shortened daylight hours and colder weather make it sooooohhh difficult to get up early and exercise. I also instinctively look for starchy foods instead of fresh fruits and vegetables. Our pets face the same problems. 

Wild animals in colder climates slow down their metabolism and hibernate during winter months as temperatures drop and food becomes scarce. Domesticated dogs and cats are not so far removed from their wild ancestors that their own bodies react the same way. How do we avoid the inertia that inevitably sets in with winter weather?

The first thing is to keep an exercise routine in place. One of the few advantages of global warming is although temperatures drop, we don’t see as much snow and ice as in previous years. Sticking with daily walks helps keep their (and our) waistline at a manageable diameter. When the weather is not cooperating and our pets only go out long enough to do their business consider an indoor exercise routine. Rolling a ball to play fetch or using toys designed for cats to induce their stalking instincts are viable alternatives to playing outside. 

The second phase of our New Year’s resolutions is to take a closer look at calorie intake during colder months. I always recommend evaluating how many treats, rawhides, table scraps, etc. our pets receive. During the winter months we may need to decrease or eliminate these extras. 

I also see a lot of pets that gain weight the winter after they’ve been spayed or neutered and that can be difficult to take off again. Studies have shown that spaying and neutering dogs and cats does slow metabolism but, just because your pet was spayed or neutered does not mean that they will automatically become obese if we monitor their calorie intake and adjust properly. 

If we are exercising and reducing calories but not seeing a reduction in weight, it’s time to talk to our veterinarian about underlying disease. Glandular disorders such as underactive thyroid in dogs can lead to obesity and, without thyroid supplementation, no amount of diet and exercise will help them. Older dogs and cats frequently suffer from obesity secondary to arthritis. These pets exercise less because they are unable to move like when they were younger. 

Supplements and medications are available to help make them more comfortable and exercise more. Increased exercise and subsequent weight loss could reduce or eliminate medications (I recommend supplements lifelong).  

I hope this information is helpful in keeping our pets from gaining too much during the winter months. Now, onto my New Year’s resolution … UGH!!!

Dr. Kearns practices veterinary medicine from his Port Jefferson office and is pictured with his son Matthew and his dog Jasmine. Have a question for the vet? Email it to [email protected] and see his answer in an upcoming column.

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Stocking the fridge with healthy foods is a great way to start off the New Year. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

It is now the second week in January, and most of us have made a New Year’s resolution – or many of them. 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”?

Setting a goal that is simple and singular helps. We often overdo it by focusing on multiple resolutions, like eating better, exercising more and sleeping better. While these are all admirable, their complexity diminishes your chances of success. Instead, pick one to focus on, and make the desired impact part of your goal. For example, 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. 

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. Willpower, Katz notes, is analogous to holding your breath underwater; it is only effective for a short timeframe. 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 study, people with the most self-control utilize the least amount of willpower, because they take a proactive role in minimizing temptation (1). Start by changing the environment in your kitchen.

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 to 254 days (2). 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 & World Report released its annual ranking of diets last week (3). Three of the diets highlighted include the DASH (Dietary Approach to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. These were the top three for heart health. The Mediterranean diet was ranked number one overall, and the DASH diet was ranked second. Both the Ornish and the DASH diets ranked in the top six. 

What do all of the top diets have in common? They focus on nutrient-dense foods. In fact, the lifestyle modifications I recommend are based on a combination of the top 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 lb vs. 2 kg/4.4 lb), as well as in HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (4). 

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 macronutrients. The DASH diet also contained food 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. 

I will share one more tip: Take it day by day, rather than obsessing on the larger picture. Health and weight loss can – and should – go together.

References:

(1) J Pers Soc Psychol. 2012;102:22-31. (2) European Journal of Social Psychology, 40: 998–1009. (3) www.usnews.com. (4) Diabetes Care. 2011;34:55-57.

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

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Diet and exercise are the first line of defense for those living with diabetes. Stock photo

Taking your blood pressure medications at night has beneficial effects

By David Dunaief, M.D.

Dr. David Dunaief

Not surprisingly, soda – with 39 grams of sugar per 12-ounce can – is associated with increased risk of diabetes. However, the drink with the lowest amount of sugar is wine, red or white. Even more surprising, it may have benefits in reducing complications associated with diabetes. Wine has about 1.2 grams of sugar in 5 ounces. Per ounce, soda has the most sugar, and wine has the least.

Why is this important? The prevalence of diabetes currently sits at 9.4 percent of the U.S. population, while another 84 million have prediabetes (HbA1C of 5.7-6.4 percent) (1).

For those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women had greater risk than men. In one study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (2). This was a retrospective (backward-looking) study.

What may reduce risks of disease and/or complications? Fortunately, we are not without options. Several factors may help. These include the timing of blood pressure medications, lifestyle modifications (diet and exercise) and, yes, wine.

Diet trumps drugs for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin, 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. While these are impressive results that speak to the use of lifestyle modification and to metformin, this is not the optimal diabetes diet.

Is wine really beneficial?

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (4).

Patients were randomized into three groups, each receiving a drink with dinner nightly; one group received 5 ounces of red wine, another 5 ounces of white wine, and the control group drank 5 ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed on how to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Drugs (not diabetes drugs) show good results

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (5). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. 

Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a nonideal diet, in comparison to medication, had better results, though medication such as metformin could be used in high-risk patients that were having trouble following the diet. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Ann Intern Med. 2015;163(8):569-579. (5) Diabetologia. Online Sept. 23, 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.

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