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Dr. David Dunaief

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The list of fiber’s health benefits is growing

By David Dunaief, M.D.

Dr. David Dunaief

According to the most recent USDA survey data, Americans are woefully deficient in fiber, consuming between 10 and 15 grams per day. Breaking it down further into fiber subgroups, consumption levels for legumes and dark green vegetables are the lowest in comparison to suggested levels (1). This has pretty significant implications for our overall health and weight.

Still, many people worry about getting enough protein. 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 to the degree that studies illustrate with fiber.

So, how much fiber is enough? USDA guidelines stratify their recommendations based on gender and age. For adult women, they recommend between 22 and 28 grams per day, and for adult men, the targets are between 28 and 35 grams (1). Some argue that even these recommendations are on the low end of the scale for optimal health.

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.

All fiber is not equal

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, one irritable bowel syndrome (IBS) study (2). It was a meta-analysis of 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Reducing disease risk and mortality

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 (3). 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 antioxidant effects of whole grains that are responsible for the positive results.

A study published in 2019 that performed systematic reviews and meta-analyses on data from 185 prospective studies and 58 clinical trials found that higher intakes of dietary fiber and whole grains provided the greatest benefits in protecting participants from cardiovascular diseases, type 2 diabetes, and colorectal and breast cancers, along with a 15-30 percent decrease in all-cause mortality for those with the highest fiber intakes, compared to those with the lowest (4).

We also 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 (5). 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.

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 (6). 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 is continually expanding.

Where is the fiber?

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. 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 recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages: it helps you avoid processed foods, reduces your risk of chronic disease, and increases your satiety and 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) USDA.gov. (2) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (3) Arch Intern Med. 2011;171(12):1061-1068. (4) Lancet. 2019 Feb 2;393(10170):434-445. (5) Amer J Epidemiology 2008;167(5):570-578. (6) Amer J Clinical Nutrition 2009;90(3):664–671. 

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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Glass of wine. Pixabay photo
Family history and disease risk play big roles

By David Dunaief, M.D.

Dr. David Dunaief

Is drinking alcohol good for you or bad for you? It’s one of the most widely used over-the-counter drugs, and yet there is still confusion over whether it benefits or harms to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing.

Several studies tout alcohol’s health benefits, while others warning of its risks. The diseases addressed by these studies include breast cancer, heart disease and stroke. Remember, context is the determining factor when evaluating alcohol consumption.

Weighing Breast Cancer Risk

In a meta-analysis of 113 studies, there was an increased risk of breast cancer with daily consumption of alcohol (1). The increase was a modest, but statistically significant, four percent, and the effect was seen at one drink or less a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

Less is more when drinking alcohol. METRO photo

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increases the risk of breast cancer modestly over a 28-year period (2). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, with one to two drinks per day increasing risk to 22 percent, while those having three or more drinks per day had a 51 percent increased risk.

Alcohol’s impact on breast cancer risk is being actively studied, considering types of alcohol, as well as other mitigating factors that may increase or decrease risk. We still have much to learn.

Based on what we think we know, if you are going to drink, a drink several times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes the effect, although it might (3).

Effect on Stroke Risk

On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (4). This analysis involved over 83,000 women. Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

However, women who consumed more experienced a decline in benefits, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients should not drink alcohol solely to get stroke protection benefits.

If you’re looking for another option to achieve the same benefits, an analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (5).

The citrus fruits used most often in this study were oranges and grapefruits. Note that grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (6).

Effect on Heart Attack Risk

In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more or were non-drinkers (7). Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits. This study has a high durability spanning 20 years.

What’s the Answer?

Moderation is the key. It is important to remember that alcohol is a drug that does have side effects, including insomnia. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more. To get the stroke benefits and avoid the increased breast cancer risk, half a glass of alcohol per day may be the ideal amount for women. Moderate amounts of alcohol for men are up to two glasses daily, though one glass showed significant benefits. 

Remember, there are other ways of reducing your risks that don’t require alcohol. However, if you enjoy it, modest amounts may reap some health benefits.

References: 

(1) Alc and Alcoholism. 2012;47(3)3:204–212. (2) JAMA. 2011;306:1884-1890. (3) JAMA. 2011;306(17):1920-1921. (4) Stroke. 2012;43:939–945. (5) Stroke. 2012;43:946–951. (6) Medscape.com. (7) Eur Heart J. Published online March 28, 2012.

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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Addressing issues affecting mobility are crucial to reducing risk

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease still ranks as the number 1 cause of death in the U.S., with just under 700,000 deaths per year, which equates to just over 200 deaths per 100,000 people (1). Depending on your ethnicity, your risk might be higher or lower than the average.

While this is certainly better than it used to be, we have a long way to go to reduce the risk of heart disease. 

Some risk factors are obvious. Others are not. 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 ones include gout, atrial fibrillation and osteoarthritis. 

The good news is that we have more control than we think. Most of these risks can be significantly reduced with lifestyle modifications.

Let’s look at the evidence.

Is obesity an independent risk factor?

Obesity continually gets play in discussions of disease risk. But how substantial a risk factor is it?

In the Copenhagen General Population Study, results showed an increased heart attack risk in those who were overweight and in those who were obese with or without metabolic syndrome, which includes a trifecta of high blood pressure, high cholesterol and high sugar levels (2). “Obese” was defined as a body mass index (BMI) over 30 kg/m², while “overweight” included those with a BMI over 25 kg/m².

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. However, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Because this was an observational trial, the results represent an association between obesity and heart disease. Basically, it’s telling us that there may not be such a thing as a “metabolically healthy” obese patient. If you are obese, this is one of many reasons that it’s critical to lose weight.

Activity levels drive improvements

Let’s consider another lifestyle factor, the impact of being sedentary. An observational study found that activity levels had a surprisingly high impact on women’s heart disease risk (3). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect. 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 age 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, it may have been underestimated as a risk factor. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

How long do you suffer with 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? 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 (4). 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.

When does fiber matter most?

Studies show that fiber decreases the risk of heart attacks. However, does fiber still matter once 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 (5).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is that those who increased their fiber after a cardiovascular event had a 31 percent reduction in mortality risk. The most intriguing part of the study was the dose response. For every 10-gram increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality.

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 (6).

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) cdc.gov. (2) JAMA Intern Med. 2014;174(1):15-22. (3) Br J Sports Med. 2014, May 8. (4) PLoS ONE. 2014, Mar 14, 2014. [https://doi.org/10.1371/journal.pone.0091286]. (5) BMJ. 2014;348:g2659. (6) N Engl J Med. 2000;343(1):16.

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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Long-term use of PPIs can cause dementia and chronic kidney disease. METRO photo
Over-the-counter PPIs should be taken for no more than 14 days

By David Dunaief, MD

Dr. David Dunaief

Gastroesophageal reflux disease (GERD) is one of the most commonly treated diseases in the U.S. While it is sometimes referred to as heartburn, this really a symptom. Proton pump inhibitors (PPIs), first launched in the late 1980s, have grown to become one of the top-10 drug classes prescribed or taken over-the-counter (OTC).

When they were first approved, they were touted as having one of the cleanest side-effect profiles. This may still be true, if we use them correctly. They are intended to be used for the short term only. 

PPIs currently available OTC include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), and Aciphex (rabeprazole). These and others are also available by prescription.

The FDA indicates that OTC PPIs should be taken for no more than a 14-day treatment once every four months. Prescription PPIs should be taken for 4 to 8 weeks (1).

While PPI pre-approval trials were short-term, many take these medications long-term. And the longer people are on them, the more complications arise. Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

Chronic kidney disease

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (2). All of the patients started the study with normal kidney function based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a 17 percent increased risk. 

The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (3).

Dementia risk

A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (4). These patients were at least age 75. The authors surmise that PPIs may cross the blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk. Researchers also did not take into account family history of dementia, high blood pressure or excessive alcohol use, all of which have effects on dementia occurrence.

Bone fracture risk

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (5). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption through the gut. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (6).

Absorption of magnesium, calcium and B12

PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (7). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

Another study confirmed these results. In this second study, which was a meta-analysis of nine studies, PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (8). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

The bottom line

It’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as an H2 blocker (Zantac, Pepcid). In addition, PPIs may interfere with other drugs you are taking, such as Plavix (clopidogrel).

Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (9).

If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration.

References: 

(1) fda.gov. (2) JAMA Intern Med. 2016;176(2). (3) JAMA Intern Med. 2016;176(2):172-174. (4) JAMA Neurol. online Feb 15, 2016. (5) Osteoporos Int. online Oct 13, 2015. (6) Am J Med. 118:778-781. (7) PLoS Med. 2014;11(9):e1001736. (8) Ren Fail. 2015;37(7):1237-1241. (9) Am J Gastroenterol 2015; 110:393–400. 

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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Drinking milk and consuming other dairy products may actually be harmful. METRO photo
Revisiting dairy, calcium and vitamin D

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis in the U.S. is increasing as the population ages, especially among women. Why is this important? Osteoporosis may lead to increased risk of fracture due to a decrease in bone strength (1). Hip fractures are most concerning, because they increase mortality risk dramatically. In addition, more than 50 percent of hip fracture survivors lose the ability to live independently (2).

That is what we know. But what about what we think we know?

The importance of drinking milk for strong bones has been drilled into us since we were toddlers. Milk has calcium and is fortified with vitamin D, so milk could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that milk may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.”

We need Vitamin D and calcium for strong bones, but do supplements help prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

Let’s look more closely at what the research tells us.

Milk and dairy

The results of a large, observational study involving men and women in Sweden showed that milk may actually be harmful (3). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, three percent per glass increased risk of death in men. For both men and women, biomarkers that indicate higher levels of oxidative stress and inflammation were found in the urine.

This 20-year study was eye-opening. We cannot make any decisive conclusions, only associations, since it is not a randomized controlled trial. But it does get you thinking. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume about three cups of dairy per day (4). Prior studies show milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (5).

In a 2020 meta-analysis of an array of past studies, researchers concluded that increased consumption of milk and other dairy products did not lower osteoporosis and hip fracture risks (6).

Reconsidering calcium

Unfortunately, it is not only milk that may not be beneficial. In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food on a daily basis (7).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of the large multivaried meta-analyses is that vitamin D baseline levels, exercise and phosphate levels were not taken into account.

What about vitamin D?

Finally, though the data is not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (8). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Where does that leave us?

Just because something in medicine is a paradigm does not mean it’s correct. Milk and dairy may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. However, the patients in these trials were not necessarily deficient in calcium or vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, older patients may need at least 800 IUs per day, which is the Institute of Medicine’s recommended amount for a population relatively similar to the one in the study.

Remember that studies, though imperfect, are better than tradition alone. Prevention and treatment therefore should be individualized, and deficiency in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References: 

(1) JAMA. 2001;285:785-795. (2) EndocrinePractice. 2020 May;26(supp 1):1-46. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Crit Rev Food Sci Nutr. 2020;60(10):1722-1737. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

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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Lignans found in plants can reduce risk. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

It’s always surprising the number of myths that still circulate about type 2 diabetes, considering its prevalence in the U.S. Science is continually advancing what we know about diabetes risk and disease management, and some older interpretations deserve to be retired. Let’s take a look at a few common myths and the research that debunks them.

MYTH: Fruit should be limited or avoided.

Fruit, whether whole fruit, fruit juice or dried fruit, has been long considered taboo for those with diabetes. This is only partially true.

Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the fruits’ flavonoids, or plant micronutrients, but another is the fiber.

MYTH: All carbohydrates raise your sugars.

Fiber is one type of carbohydrate that has distinct benefits. We know fiber is important for reducing risk for a host of diseases and for managing their outcomes, and it is not any different for diabetes. 

In the Nurses’ Health Study (NHS) and NHS II, two very large prospective observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and whole grains (5). The researchers could not determine which plants contributed the greatest benefit. The researchers believe the effect results from antioxidant activity.

MYTH: Soy should be avoided when you have diabetes.

In diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (6). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

This was a small randomized control trial over a four-year period with 41 participants. The control group’s diet consisted of 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

MYTH: Bariatric surgery is an alternative to lifestyle changes.

Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery involving 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintaining long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order to sustain its benefits.

References: 

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Obes Surg. 2014;24:437-455.

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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METRO photo
NSAIDS con contribute to kidney damage

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that the CDC estimates as many as 15 percent of U.S. adults have chronic kidney disease (CKD) and that roughly 90 percent of them don’t know they have it (1). This includes about 50 percent of people with a high risk of kidney failure in the next five years.

How is this possible? CKD is tricky because it tends to be asymptomatic, initially. Only in the advanced stages do symptoms become distinct, although there can be vague symptoms in moderate stages such as fatigue, malaise and loss of appetite. Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease. But those are only the ones at highest risk.

Why does CKD matter?

Your kidneys function as efficient little blood filters. They remove wastes, toxins and excess fluid from the body. In addition, they play roles in controlling blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in the blood. When they’re not operating at full capacity, the consequences can be heart disease, stroke, anemia, infection and depression — among others. According to the U.S. Preventive Services Task Force and the American College of Physicians, those who are at highest risk should be screened including patients with diabetes or hypertension (2)(3).

Slowing CKD progression

Fortunately, there are several options available, ranging from preventing CKD with specific exercise to slowing the progression with lifestyle changes and medications.

Exercise helps – even walking

The results of a study show that walking reduces the risk of death and the need for dialysis by 33 percent and 21 percent respectively (4). Even more intriguing, those who walked more often saw greater results. So, the participants who walked one-to-two times a week had a significant 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a more impressive 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. There were 6,363 participants with an average age of 70, and they were followed for an average of 1.3 years.

How much protein to consume?

When it comes to CKD, more protein is not necessarily better, and it may even be harmful. In a meta-analysis of 17 Cochrane database studies of non-diabetic CKD patients who were not on dialysis, results showed that the risk of progression to end-stage kidney disease, including the need for dialysis or a kidney transplant, was reduced 36 percent in those who consumed a very low-protein diet, rather than a low-protein or normal protein diet (5).

Reducing sodium consumption

Good news! In a study, results showed that a modest sodium reduction in our diet may be sufficient to help prevent proteinuria (protein in the urine) (6). Here, less than 2000 mg was shown to be beneficial, something all of us can achieve.

Medications have a place

We routinely give certain medications, ACE inhibitors or ARBs, to patients who have diabetes to protect their kidneys. What about patients who do not have diabetes? ACEs and ARBs are two classes of anti-hypertensives — high blood pressure medications — that work on the kidney systems responsible for blood pressure and water balance (7). Results of a study show that these medications reduced the risk of death significantly in patients with moderate CKD. Most of the patients were considered hypertensive.

However, there was a high discontinuation rate among those taking the medication. If you include the discontinuations and regard them as failures, then all who participated showed a 19 percent reduction in risk of death, which was significant. However, if you exclude discontinuations, the results are much more robust with a 63 percent reduction. To get a more realistic picture, this result, including both participants and dropouts, is probably close to what will occur in clinical practice unless the physician is a really good motivator or has very highly motivated patients.

Should you be taking NSAIDs?

Non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen, have been associated with CKD progression and with kidney injury in those without CKD (1). For those on ACE inhibitors or ARBs, NSAIDs can also interfere with their effectiveness. Talk to your doctor about your prescription NSAIDs and any other over-the-counter medications you are taking.

Takeaways

You don’t necessarily have to rely on drug therapies to protect your kidneys, and there is no down-side to lifestyle modifications. Lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options, with or without medication. Discuss with your physician whether you need regular screening. High-risk patients with hypertension and diabetes should definitely be screened; however, those with vague symptoms of lethargy, aches and pains might benefit from screening, as well.

References: (1) cdc.gov/kidneydisease (2) uspreventiveservicestaskforce.org (3) aafp.org. (4) Clin J Am Soc Neph-rol. 2014;9(7):1183-9. (5) Cochrane Database Syst Rev. 2020;(10):CD001892. (6) Curr Opin Nephrol Hypertens. 2014;23(6):533-540. (7) J Am Coll Cardiol. 2014;63(7):650-658.

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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A daily quarter-teaspoon increase in sodium can affect kidney function

By David Dunaief, M.D

Dr. David Dunaief

Approximately 37 million U.S. adults have chronic kidney disease (CKD), with as many as 9 in 10 not aware they have it, according to the CDC (1).

Early-stage CKD is associated with a 40 percent increased risk of developing cardiovascular events, such as heart attacks (2). It also significantly increases the risk of peripheral artery disease (PAD). Those with decreased kidney function have a 24 percent prevalence of PAD, compared to 3.7 percent in those with normal kidney function (3). Ultimately, it can progress to end-stage renal (kidney) disease, requiring dialysis and potentially a kidney transplant, so it’s important to identify and treat it.

However, one of the problems with early-stage CKD is that it tends to be asymptomatic. However, there are simple tests, such as a basic metabolic panel and a urinalysis, that will indicate whether you may have mild chronic kidney disease. These indices for kidney function include an estimated glomerular filtration rate (eGFR), creatinine level and protein in the urine. eGFR is a calculation, and while the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 is considered to have mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the severity of chronic kidney disease increases.

What can be done to stem early-stage CKD, before complications occur? There are several studies that have looked at medications and lifestyle modifications and their impacts on its prevention, treatment and reversal.

Does Allopurinol help?

Allopurinol is usually thought of as a medication to prevent gout. 

However, in a randomized controlled trial with 113 patients, results show that allopurinol may help to slow the progression of CKD, defined in this study as an eGFR less than 60 (4). The group using 100 mg of allopurinol showed significant improvement in eGFR levels (compared to the control group) over a two-year period. The researchers concluded that allopurinol slowed CKD progression. Allopurinol also decreased cardiovascular risk by 71 percent.

A 2018 study published in the Journal of the American Medical Association, concluded that allopurinol at a dose of 300 mg or higher reduced the risk of developing stage 3 kidney disease, but less than 300 mg did not (5). However, there is a much smaller 2020 study that shows allopurinol does not help to slow the progression of CKD stage 3 patients (6). This study was very small, but it does raise a question about whether allopurinol truly works.

Diet’s impact

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (7).

What is the significance of metabolic acidosis? It means that body fluids become acidic, and it is associated with chronic kidney disease. The authors concluded that both sodium bicarbonate and a diet including fruits and vegetables were renoprotective, helping to protect the kidneys from further damage in patients with CKD. Alkali diets are primarily plant-based, although not necessarily vegetarian or vegan. Animal products tend to cause an acidic environment.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (8). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower levels of eGFR.

The most interesting part with sodium was that the difference between higher mean consumption and the lower mean consumption was not that large, 2.4 grams compared to 1.7 grams. In other words, a difference of approximately a quarter-teaspoon of sodium was responsible for the decrease in kidney function.

In my practice, when CKD patients follow a vegetable-rich, nutrient-dense diet, there are substantial improvements in kidney functioning. For instance, for one patient, his baseline eGFR was 54. After one month of lifestyle modifications, his eGFR improved by 9 points to 63, which is a return to “normal” functioning of the kidney. Note that this is an anecdotal story and not a study.

Therefore, it is important to have your kidney function checked with mainstream tests. If the levels are low, you should address the issue through medications and lifestyle modifications to manage and reverse early-stage CKD. If you have common risk factors, such as diabetes, smoking, obesity or high blood pressure, or if you are over 60 years old, talk to your doctor about testing. 

Don’t wait until symptoms and complications occur. In my experience, it is much easier to treat and reverse a disease in its earlier stages, and CKD is no exception.

References: 

(1) CDC.gov. (2) N Engl J Med. 2004;351:1296-1305. (3) Circulation. 2004;109:320–323. (4) Clin J Am Soc Nephrol. 2010 Aug;5:1388-1393. (5) JAMA Intern Med. 2018;178(11):1526-1533. (6) N Engl J Med 2020; 382:2504-2513. (7) Clin J Am Soc Nephrol. 2013;8:371-381. (8) Clin J Am Soc Nephrol. 2010; 5:836-843. 

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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Most Americans underconsume potassium   

By David Dunaief, M.D.

Dr. David Dunaief

Most of us know we need to lower our sodium intake. Still, more than 90 percent of us consume far too much sodium (1). Even if we don’t have hypertension, the impact of sodium on our health can be dramatic.

Sodium is insidious; it’s in foods that don’t even taste salty. Bread products are among the primary offenders. Other foods with substantial amounts of sodium include cold cuts and cured meats, cheeses, pizza, poultry, soups, pastas, sauces and, of course, snack foods. Processed foods and those prepared by restaurants are where most of our consumption occurs (2).

On the flip side, only about two percent of people get enough potassium from their diets (3).

Why is it important to reduce sodium and increase potassium? A high sodium-to-potassium ratio increases the risk of cardiovascular disease by 46 percent, according to the study, which looked at more than 12,000 Americans over almost 15 years (4). In addition, both may have significant impacts on blood pressure and cardiovascular disease.

To improve our overall health, we need to shift the sodium-to-potassium balance so that we consume more potassium and less sodium. And if you struggle with high blood pressure, this approach could help you win the battle. Let’s look at the evidence.

Why do we always harp on sodium?

Two studies illustrate the benefits of reducing sodium in high blood pressure and normotensive (normal blood pressure) patients, ultimately preventing cardiovascular disease, including heart disease and stroke.

The first used the prestigious Cochrane review to demonstrate that blood pressure is reduced by a significant mean of −4.18 mm Hg systolic (top number) and −2.06 mm Hg diastolic (bottom number) involving both normotensive and hypertensive participants (5). When looking solely at hypertensive patients, the reduction was even greater, with a systolic blood pressure reduction of −5.39 mm Hg and a diastolic blood pressure reduction of −2.82 mm Hg.

This was a meta-analysis (a group of studies) that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. Salt reduction from 9 to 12 grams per day to 5 to 6 grams per day, determined using 24-hour urine tests, had a dramatic effect. The researchers believe there is a direct linear effect with salt reduction. In other words, the more we reduce the salt intake, the greater the effect of reducing blood pressure. 

The authors recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

In the second study, a meta-analysis of 42 clinical trials, there was a similarly significant reduction in both systolic and diastolic blood pressures (6). This study included both adults and children. Both demographics saw a reduction in blood pressure, though the effect was greater in adults. Interestingly, an increase in sodium caused a 24 percent increased risk of stroke incidence but, more importantly, a 63 percent increased risk of stroke mortality. The risk of mortality from heart disease was increased alongside an increase in sodium, as well, by 32 percent.

In an epidemiology modeling study, the researchers projected that either a gradual or instantaneous reduction in sodium would save lives (7). For instance, a modest 40 percent reduction over 10 years in sodium consumed could prevent 280,000 premature deaths. These are only projections, but in combination with the above studies, they may be telling.

Why is potassium important?

When we think of blood pressure, not enough attention is given to potassium. The typical American diet doesn’t contain enough of this mineral.

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (8). When foods containing 3.5 to 4.7 grams of potassium were consumed, there was an impressive −7.16 mm Hg reduction in systolic blood pressure with high blood pressure patients. Anything more than this amount of potassium did not have any additional benefit. Increased potassium intake also reduced the risk of stroke by 24 percent. This effect was important.

The reduction in blood pressure was greater with increased potassium consumption than with sodium restriction, although this was not a head-to-head comparison. The good news is that potassium is easily attainable in the diet. Foods that are potassium-rich include bananas, almonds, raisins, sweet potato and green leafy vegetables such as Swiss chard.

The bottom line: decrease your sodium intake by almost half and increase potassium intake from foods. Lowering sodium intake may have far-reaching benefits, and it is certainly achievable. First, consume less and give yourself a brief period to adapt — it takes about six weeks to retrain your taste buds, once you cut your sodium. You can also improve your odds by increasing your dietary potassium intake, which also has a substantial beneficial effect, striking a better sodium-to-potassium balance.

References: 

(1) Am J Clin Nutr. 2012 Sep;96(3):647-657. (2) www.cdc.gov. (3) Am J Clin Nutr. 2012 Sep;96(3):647-657. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) BMJ. 2013 Apr 3;346:f1325. (6) BMJ. 2013 Apr 3;346:f1326. (7) Hypertension. 2013; 61: 564-570. (8) BMJ. 2013; 346:f1378.

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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By David Dunaief, MD

Dr. David Dunaief

If you are one of the 32.5 million in the U.S. who suffers from osteoarthritis, you know it can make it painful to perform daily tasks. Osteoarthritis (OA) most often affects the knees, hips and hands and can affect sleep quality and mood, in addition to mobility.

Common first-line medications for arthritis pain are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, while medications treat the immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression, and they do have side effects, especially with long-term use.

Here, we’ll focus on approaches you can use to ease pain without reaching for the medicine cabinet. Some may slow worsening — or even reverse symptoms — of your osteoarthritis.

Does dairy help or hurt?

With dairy, specifically milk, there is conflicting information. Some studies show benefits, while others show that it may contribute to the inflammation that makes osteoarthritis pain feel worse.

In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (1). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

The result curve was interesting, however. For those who drank from fewer than three glasses a week up to 10 glasses a week, the progression of joint space narrowing was slowed. However, for those who drank more than 10 glasses per week, there was less beneficial effect. There was no benefit seen in men or with the consumption of higher fat products, such as cheese or yogurt.

However, the study was observational and had significant flaws. First, the 2100 patients were only asked about their milk intake at the study’s start. Second, patients were asked to recall their weekly milk consumption for the previous 12 months before the study began — a challenging task.

On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (2).

Getting more specific, a published analysis of the Framingham Offspring Study found that those who consumed yogurt had statistically significant lower levels of interleukin-6 (IL-6), a marker for inflammation, than those who didn’t eat yogurt, but that this was not true with milk or cheese consumption (3).

We are left with more questions than answers. Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I may not dissuade osteoarthritis patients from yogurt.

Does vitamin D help?

Over the last decade, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief, nor any disease-modifying effects (4). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

The role of weight

Weight management is a crucial component of any OA pain management strategy. In a study involving 112 obese patients, those who lost weight reported a reduction of knee symptoms. Even more exciting, there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5).

On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet for the win!

Diet and exercise trumped the effects of diet or exercise alone in a well-designed study (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a randomized controlled single-blinded study with a duration of 18 months.

Researchers used biomarker IL6 to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times a week.

Therefore, concentrate on lifestyle modifications to reduce pain and potentially disease-modifying effects. The best effects shown are with weight loss and with a vegetable-rich diet. In terms of low-fat or nonfat milk, the results are controversial at best. For yogurt, the results suggest it may be beneficial for osteoarthritis, but stay on the low end of consumption, since dairy can increase inflammation.

References: 

(1) Arthritis Care Res online. 2014 April 6. (2) J Rheumatol. 2017 Jul;44(7):1066-1070. (3) Nutrients. 2021 Feb 4;13(2):506. (4) JAMA. 2013;309:155-162. (5) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (6) JAMA. 2013;310:1263-1273.

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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