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Dr. David Dunaief

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Medications and lifestyle changes can reduce your risk

By David Dunaief, M.D.

Dr. David Dunaief

With all of the attention on infectious disease prevention these past two years, many have lost sight of the risks of heart disease. Despite improvements in the numbers in recent years, heart disease still underpins one in four deaths in the U.S., making it the leading cause of death (1).

Heart disease is on the decline due to a number of factors, including better awareness in lay and medical communities, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. Heart disease is something that is eminently preventable.

Reduce your baseline risks

Significant risk factors for heart disease include high cholesterol, high blood pressure and smoking. In addition, diabetes, excess weight and excessive alcohol intake increase your risks. Unfortunately, both obesity and diabetes are on the rise. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2).

Inactivity and the standard American diet, rich in saturated fat and calories, also contribute to heart disease risk (3). The underlying culprit is atherosclerosis, fatty streaks in the arteries.

Another potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (4). A normal resting heart rate is usually between 60 and 100 bpm. Thus, you don’t have to have a racing heart rate, just one that is high-normal. All of these risk factors can be overcome.

Medication’s role in reducing risk

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. Unfortunately, according to 2018 National Health and Nutrition Examination Survey (NHANES) data, only 43.7 percent of those with hypertension have it controlled (5). While the projected reasons are complex, a significant issue among those who are aware they have hypertension is a failure to consistently take prescribed medications, or medication nonadherence.

In terms of lipids, statins have played a key role in primary prevention. Statins are effective at not only lowering lipid levels, including total cholesterol and LDL — the “bad” cholesterol — but also inflammation levels that contribute to the risk of cardiovascular disease. The JUPITER trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

The downside of statins is their side effects. Statins have been shown to increase the risk of diabetes in intensive dosing, compared to moderate dosing (6).

Unfortunately, many on statins also suffer from myopathy (muscle pain). I have had a number of patients who have complained of muscle pain and cramps. Their goal is to reduce and ultimately discontinue their statins by following a lifestyle modification plan involving diet and exercise. Lifestyle modification is a powerful ally.

Do lifestyle changes really help?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required a modest change in diet.

The Nurses’ Health Study shows that these results are also seen in women, with lifestyle modification reducing the risk of sudden cardiac death (SCD). Many times, this is the first manifestation of heart disease in women. The authors looked at four parameters of lifestyle modification, including a Mediterranean-type diet, exercise, smoking and body mass index. The decrease in SCD that was dose-dependent, meaning the more factors incorporated, the greater the risk reduction. SCD risk was reduced up to 92 percent when all four parameters were followed (8). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

Monitoring your heart disease risk

To monitor your progress, cardiac biomarkers are telling, including inflammatory markers like C-reactive protein, blood pressure, cholesterol and body mass index. 

In a cohort study of high-risk participants and those with heart disease, patients implemented extensive lifestyle modification: a plant-based, whole foods diet accompanied by exercise and stress management (9). The results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life. Most exciting is that results occurred over a very short period to time — three months from the start of the trial. Many of my patients have experienced similar results.

Ideally, if patient needs to use medications to treat risk factors for heart disease, it should be for the short term. For some patients, it may be appropriate to use medication and lifestyle changes together; for others, lifestyle modifications may be sufficient, as long as patient takes an active role.

By focusing on developing heart-healthy habits, we can improve the likelihood that we will be around for a long time.

References: 

(1)cdc.gov/heartdisease/facts.(2) Diabetes Care. 2010 Feb; 33(2):442-449. (3) Lancet. 2004;364(9438):93. (4) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (5) Hypertension. 2022;79:e1–e14. (6) JAMA. 2011;305(24):2556-2564. (7) J Nutr. March 1, 2005;135(3):556-561. (8) JAMA. 2011 Jul 6;306(1):62-69. (9) Am J Cardiol. 2011;108(4):498-507.

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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Inflammatory responses are at the heart of allergy symptoms        

By David Dunaief, M.D.

Dr. David Dunaief

After last week’s extended blast of winter, we’re all looking forward to warmer weather. This past weekend, we adjusted our clocks for Daylight Saving Time, the unofficial end of winter. We’re just a few weeks out from tree buds and daffodil sprouts. What joy!

However, for people who suffer from seasonal allergic rhinitis, hay fever, seasonal allergies or whatever you would like to call it, life is about to get miserable.

Just over 19 million U.S. adults were diagnosed with seasonal allergies in 2018, and an additional 5.2 million children were diagnosed, according to the Centers for Disease Control and Prevention (1).

The triggers for seasonal allergies are diverse. They include pollen from leafy trees and shrubs, grass and flowering plants, as well as weeds, with the majority from ragweed (mostly in the fall) and fungus (summer and fall) (2).

What triggers allergic reactions? 

A chain reaction occurs in seasonal allergy sufferers. When foreign substances such as allergens (pollen, in this case) interact with immunoglobulin E (IgE), antibodies that are part of our immune system, they cause mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response.

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it emulates a cold, but without the virus. If symptoms last more than 10 days and are recurrent, then it is more than likely you have allergies.

If allergic rhinitis is not properly treated, complications such as ear infections, sinusitis, irritated throat, insomnia, chronic fatigue, headaches and even asthma can result (4).

Treating allergies with medications

The best way to treat allergy attacks is to prevent them, but this can mean closing yourself out from the enjoyment of spring by literally closing the windows, using the air-conditioning, and using recycling vents in your car.

On the medication side, we have intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops, and leukotriene modifiers (second-line treatment only).

The guidelines for treating seasonal allergic rhinitis with medications suggest that intranasal corticosteroids (steroids) should be used when quality of life is affected. If there is itchiness and sneezing, then second-generation oral antihistamines may be appropriate (5). Two well-known inhaled steroids are Nasacort (triamcinolone) and Flonase (fluticasone propionate). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day and do have side effects.

Oral antihistamines, on the other hand, can be taken on an as-needed basis. Second-generation antihistamines, such as loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra), have less sleepiness as a side effect than first-generation antihistamines.

Possible alternative treatments

Butterbur (Petasites hybridus), an herb, has several small studies that indicate its efficacy in treating hay fever. In one randomized controlled trial (RCT) involving 131 patients, results showed that butterbur was as effective as cetirizine (Zyrtec) in treating this disorder (6).

In another RCT, results showed that high doses of butterbur — 1 tablet given three times a day for two weeks — was significantly more effective than a placebo (7). Researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) in the trial.

A post-marketing follow-up study of 580 patients showed that, with butterbur Ze339, symptoms improved in 90 percent of patients with allergic rhinitis over a two-week period (8). Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the population.

The caveats to the use of butterbur are several. First, the studies were short in duration. Second, the leaf extract used in these studies was free of pyrrolizidine alkaloids (PAs). This is very important, since PAs may not be safe. Third, the dose was well-measured, which may not be the case with over-the-counter extracts. Fourth, there are interactions with some prescription medications.

Can you treat allergies with diet?

While there are no significant studies on diet, there is one review of literature that suggests that a plant-based diet may reduce symptoms of allergies, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma. This is according to the International Study of Asthma and Allergies in Childhood study in 13- to 14-year-old teens (9). In my clinical practice, I have seen patients who suffer from seasonal allergies improve and even reverse the course of allergies over time with a vegetable-rich, plant-based diet, possibly due to its anti-inflammatory effect.

While allergies can be miserable, there are a significant number of over-the-counter and prescription options to help reduce symptoms. Diet may play a role in the disease process by reducing inflammation, though there are no formal studies. There does seem to be promise with some herbs, especially butterbur. However, alternative supplements and herbs lack large, randomized clinical trials with long durations. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

References: 

(1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) J Allergy Clin Immunol. 2003 Dec;112(6):1021-31.. (4) J Allergy Clin Immunol. 2010 Jan;125(1):16-29.. (5) Otolaryngol Head Neck Surg. 2015 Feb;2:197-206. (6) BMJ 2002;324:144. (7) Arch Otolaryngol Head Neck Surg. 2004 Dec;130(12):1381-6. (8) Adv Ther. Mar-Apr 2006;23(2):373-84. (9) Eur Respir J. 2001;17(3):436-443.

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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Avocados are a great source of micronutrients. METRO photo
Improving calorie quality makes a difference

By David Dunaief, M.D.

Dr. David Dunaief

The road to weight loss, or even weight maintenance, is complex. Many things influence our eating behavior, including food addictions, boredom, lack of sleep and stress. This can make weight management or weight loss very difficult to achieve.

Unfortunately, awareness of a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or encourages higher calorie purchases (1, 2).

Does this mean we are doomed to acquiesce to food temptation? Actually, no: It is not solely about willpower. Changing diet composition is more important.

In my clinical experience, increasing the quality of food has a tremendous impact. Foods that are the most micronutrient dense, such as plant-based foods, rather than those that are solely focused on macronutrient density, such as protein, carbohydrates and fats, tend to be the most satisfying. In a week to a few months of focusing on micronutrients, one of the first things patients notice is a significant reduction in cravings. But don’t take my word for it. Let’s look at the evidence.

Refined carbohydrates

Many of us know that refined carbohydrates are not beneficial. Worse, however, a randomized control trial (RCT) showed refined carbohydrates may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown by MRI scans of trial subjects.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were blinded (unaware) as to which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number of calories consumed. Granted, this was a very small study, but it was well designed. High-glycemic foods include carbohydrates, such as white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates. Calorie composition matters.

Comparing macronutrients

We tend to focus on macronutrients when looking at diets. These include protein, carbohydrates and fats, but are these the elements that have the greatest impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among groups, nor was there much success in helping obese patients reduce their weight (4, 5). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Again, focusing primarily on macronutrient levels and calorie counts did very little to improve results.

Micronutrient deficiency

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be lacking in micronutrients (6). These include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements won’t solve the problem; supplements don’t compensate for missing micronutrients. Quite the contrary, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation, by adding variety to your diet. Please ask your doctor.

Cortisol levels

The good news is that once people lose weight, they may be able to continue to keep the weight off. In a prospective (forward-looking) study, results show that once obese patients lose weight, the levels of cortisol metabolite excretion decrease significantly (7).

Why is this important? Cortisol is a glucocorticoid, which means it raises the level of glucose and is involved in mediating visceral or belly fat. This type of fat has been thought to coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality. This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about willpower or calorie-counting. While calories have an impact, the nutrient density of the food may be more important. Thus, those foods high in a variety of micronutrients may also play a significant role in reducing cravings, ultimately helping to manage weight.

References: 

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) Am J Clin Nutr Online 2013;Jun 26. (4) N Engl J Med 2009 Feb 26;360:859. (5) N Engl J Med 2009 Feb 26;360:923. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

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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Some medication side-effects include increased fall risk

By David Dunaief, M.D.

Dr. David Dunaief

This has been a particularly challenging winter here in the Northeast. Instead of snow, we’ve had a fair amount of ice and variable temperatures that caused snowy surfaces to ice over.

Many older adults are concerned about falling, thus they stayed inside and sedentary. While this addressed the immediate challenge of icy sidewalks, it may have increased their risk of falling in the future.

What drives this concern about falls? Even without icy steps and walkways, falls can be serious for older patients, where the consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability and a decline in physical and social activities (1). Ultimately, a fall can lead to loss of independence (2).

There are many factors. A personal history of falling in the recent past is the most prevalent. However, there are other significant factors, such as age and medication use. Some medications, like antihypertensive medications, which are used to treat high blood pressure, and psychotropic medications, which are used to treat anxiety, depression and insomnia, are of particular concern. Chronic diseases can also contribute.

Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (3).

Setting yourself up for success

Of the utmost importance is exercise. But what do we mean by “exercise”? We mean exercises involving balance, strength, movement, flexibility and endurance, all of which play significant roles in fall prevention (4). The good news is that many of these can be done inside with no equipment or with items found around the home.

Footwear also needs to be addressed. Nonslip shoes are crucial indoors, and footwear that prevents sliding on ice in winter, such as slip-on ice cleats that fit over your shoes, is a must. In the home, inexpensive changes, like securing area rugs and removing other tripping hazards, can also make a big difference.

Does medication increase risk?

There are a number of medications that may heighten fall risk. As I mentioned, psychotropic drugs top the list. But what other drugs might have an impact?

High blood pressure medications have been investigated. A well-designed study showed an increase in fall risk in those who were taking high blood pressure medication (5). Those on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase.

Blood pressure medications have significant benefits in reducing the risks of cardiovascular disease and events. Thus, we need to weigh the risk-benefit ratio in older patients before stopping a medication. We also should consider whether lifestyle modifications, which play a significant role in treating this disease, can be substituted for medication (6).

The value of exercise

A meta-analysis showed that exercise significantly reduced the risk of a fall (7). It led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in falls requiring medical attention. Even more impressive was a 61 percent reduction in fracture risk.

Remember, the lower the fracture risk, the more likely you are to remain physically independent. The author summarized that exercise not only helps to prevent falls but also fall injuries.

Unfortunately, those who have fallen before, even without injury, often develop a fear that causes them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased risk of falling (8).

What types of exercise help?

Any consistent exercise program that improves balance, flexibility, and muscle tone and includes core strengthening should help you improve your balance. Among those that have been studied, tai chi, yoga and aquatic exercise have all been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (9). The aim of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the overall number of falls and a 44 percent decline in the number of exercising patients who fell during the six-month trial, with no change in the control group.

If you don’t have a pool available, tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (10).

Another pilot study used modified chair yoga classes with a small assisted living population (11). Participants were those over 65 who had experienced a recent fall and had a resulting fear of falling. While the intention was to assess exercise safety, researchers found that participants had less reliance on assistive devices and three of the 16 participants were able to eliminate their use of mobility assistance devices.

Thus, our best line of defense against fall risk is prevention with exercise and reducing slipping opportunities. Should you stop medications? Not necessarily. But for those 65 and older, or for those who have arthritis and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before you consider changing your blood pressure medications, review your risk-to-benefit ratio with your physician.

References: 

(1) MMWR. 2014; 63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) JAMA. 1995;273(17):1348. (4) Cochrane Database Syst Rev. 2012;9:CD007146. (5) JAMA Intern Med. 2014 Apr;174(4):588-595. (6) JAMA Intern Med. 2014;174(4):577-587. (7) BMJ. 2013;347:f6234. (8) Age Ageing. 1997 May;26(3):189-193. (9) Menopause. 2013;20(10):1012-1019. (10) Mater Sociomed. 2018 Mar; 30(1): 38–42. (11) Int J Yoga. 2012 Jul-Dec; 5(2): 146–150.

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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Studies suggest the microbiome may influence weight loss or gain

By David Dunaief, M.D.

Dr. David Dunaief

Each of us carries trillions of microorganisms in our bodies. These make up each individual’s microbiome. It includes bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, and much of it is still only loosely understood. What we do know, however, is that these microbes have key roles in our healthy functioning.

While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where the majority of the microbiome resides.

Why do we care? The short answer is it may have a role in diseases — preventing and promoting them. These include obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

Human Microbiome Project

Like the Human Genome Project, which mapped our genes, the Human Microbiome Project, funded by the National Institutes of Health from 2007 to 2016, sought to map and sequence the composition and diversity of these gut organisms and to spur future research. There have been some enlightening preliminary studies already.

What affects the microbiome? Drugs, such as antibiotics, can wipe out the diversity in the microbes, at least in the short term. Also, lifestyle modifications, such as diet, can have an impact. Microbiome diversity also may be significantly different in distinct geographic locations throughout the world.

Microbiome’s role in obesity

Obesity can be incredibly frustrating; most obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

I know this will not come as a surprise, but we are a nation with a weight problem; about 70% of Americans are overweight or obese (2) (3). For the longest time, the paradigm for weight loss had been to cut calories. However, extreme low-caloric diets did not seem to have a long-term impact. It turns out that our guts, dominated by bacteria, may play important roles in obesity and weight loss, determining whether we gain or lose weight.

The results from a study involving human twins and mice are fascinating (4). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. But they only lost weight when on a good diet; there was no impact if the diet was not low in fat. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not clear yet which bacteria may be contributing these effects.

This definitely suggests that the diversity of gut bacteria may be a crucial piece of the weight-loss puzzle.

Possible role for gut bacteria in rheumatoid arthritis development

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant morning stiffness, joint soreness and joint breakdown. What if gut bacteria influenced RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (5). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Counteracting antibiotics’ gut effects

Many experience gastrointestinal upset while taking antibiotics. This is because antibiotics don’t differentiate between good and bad bacteria when they go to work. One way to counteract the negative effects is to take a probiotic during and after your course of antibiotics. I recommend Renew Life’s 30-50 billion units once a day, two hours after an antibiotic dose and continuing once a day for 14 days after you have finished your prescription. If you really want to ratchet up the protection, you can take one dose of probiotics two hours after every antibiotic dose.

Although nobody can say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, seem to be important to the composition and diversity of gut bacteria (6). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables and plant fiber. The research is continuing, but we’ve learned a lot already that may help us tackle obesity and autoimmune disorders.

References: 

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) cdc.gov (3) nih.gov (4) Science. 2013;341:1241214. (5) PLoS One. 2012;7:e36095. (6) Nutrients. 2019 Dec;11(12):2862.

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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Lack of exercise may rewire the brain

By David Dunaief, M.D.

Dr. David Dunaief

What do we know about the brain? Startlingly little.

Certain drugs, head injuries and lifestyle choices have negative effects. Also, numerous disorders and diseases affect the brain. Among these are neurological, infectious and rheumatologic disorders. These can include dementia, Parkinson’s, strokes, meningitis, lupus and rheumatoid arthritis. Cancer, psychiatric mood disorders, diabetes and heart disease also have potential long-term effects.

Although this list is long, it’s not exhaustive. And while these diseases vary widely, they generally have three signs and symptoms in common: they cause either altered mental status, physical weakness or change in mood — or a combination of these.

Cognitive loss, or mental decline, is a common fear and potential side effect of many of these disorders and diseases. Of course, addressing the underlying disorder is critical. Fortunately, several studies also suggest that we may be able to help our brains function more efficiently and effectively with rather simple lifestyle changes: sleep, exercise and possibly omega-3s. Let’s look at the evidence.

Clearing brain clutter

How many of us believe the stereotype that those in their 20s are sharper and quicker-witted than older folks? Are they really?

In a study, German researchers found that educated older people tend to have a larger mental database of words and phrases to pull from since they have been around longer and have more experience (1). When this is factored into the equation, the difference in terms of age-related cognitive decline becomes negligible.

This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something. We may need a reboot just like a computer. This may be possible through sleep, exercise and omega-3s.

Sleep removes brain waste

Why should we dedicate a large chunk of our lives to sleep? Researchers have identified a couple of specific values we receive from sleep: one involves clearing the mind, and another involves productivity.

For the former, a study done in mice shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (2). When we have excessive plaque buildup in the brain, it may be a sign of Alzheimer’s. When mice were sleeping, the interstitial space (the space between brain gyri, or structures) increased by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough, because cerebrospinal fluid could reach much farther into the spaces. A similar effect was seen when the mice were anesthetized.

In another study, done in Australia, results showed that sleep deprivation may have been responsible for an almost one percent decline in gross domestic product for the country (3). The reason? People are not as productive at work when they don’t get enough sleep. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness on short-term basis, we can’t do this continually.

According to the Centers for Disease Control and Prevention, 4.2 percent of respondents reported having fallen asleep in the prior 30 days behind the wheel of a car during a 2009-2010 study (4). Most commonly, these respondents also reported getting usual sleep of six hours or fewer, snoring, or unintentionally falling asleep during the day. “Drowsy driving” led to 91,000 car crashes in 2017, according to estimates from the National Highway Traffic Safety Administration (5).

Make time for exercise

How can I exercise when I can’t even get enough sleep? Well, this study may inspire you.

In the study, rats that were not allowed to exercise were found to have rewired neurons in the area of their medulla, the part of the brain involved in breathing and other involuntary activities. There was more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (6). In rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart.

This study suggests that a lack of exercise causes unwanted new connections. Human studies should be done to confirm this impact.

Omega-3 fatty acids may affect brain volume

In the Women’s Health Initiative Memory Study of Magnetic Resonance Imaging Study, results showed that those postmenopausal women who were in the highest quartile of omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (7). The hippocampus is involved in memory and cognitive function.

Specifically, the researchers looked at the levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes. The source of the omega-3 fatty acids could have been either from fish or from supplementation.

It’s never too late to improve brain function. Although we have a lot to learn about the functioning of the brain, we know that there are relatively simple ways we can positively influence it.

References: 

(1) Top Cogn Sci. 2014 Jan.;6:5-42. (2) Science. 2013 Oct. 18;342:373-377. (3) Sleep. 2006 Mar.;29:299-305. (4) cdc.gov. (5) nhtsa.gov. (6) J Comp Neurol. 2014 Feb. 15;522:499-513. (7) Neurology. 2014;82:435-442.

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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Do the benefits outweigh the risks?

By David Dunaief, M.D.

Dr. David Dunaief

Statins are one of the most commonly prescribed medications in the United States. First approved in the U.S. in 1987, they are still the “unpredictable uncle” at the pharmaceutical family table nearly 35 years later. 

Many in the medical community still disagree about who should be taking a statin and for what purpose; some believe that more patients should be on this class of drugs, while others think it is overprescribed. This is one of the most polarizing issues in medicine — probably rightly so.

The biggest debate is over primary prevention with statins. Primary prevention is treating people with high cholesterol and/or inflammation who may be at risk for a first cardiovascular event, such as a stroke or heart attack. Currently, recommendations of the American College of Cardiology and the American Heart Association do not align with those of the U.S. Preventive Services Task Force, which is currently reviewing its own recommendations because of data updates.

Most physicians agree that statins have their place in secondary prevention — treating patients who have had a stroke or heart attack already or who have coronary artery disease.

We will examine benefits and risks for the patient population that could take statins for primary prevention. On one side are those who point to statins’ benefits: reduced cancer risk, improved quality of life and lowered glaucoma risk. On the other, we have those who note statins’ side effects: increased diabetes risk, fatigue and cataracts, to name a few. Let’s look at some of the evidence.

Cancer studies

A study published in The New England Journal of Medicine involved 300,000 Danish participants and investigated 13 cancers. It showed that statin users may have a 15 percent decreased risk of death from cancer (1). As you can imagine, this news was greeted with excitement.

However, there were major limitations with the study. First, researchers did not control for smoking, which we know is a large contributor to cancer. Second, it was unknown which of the statin-using population might have received conventional cancer treatments, such as radiation and chemotherapy. Third, the dose of statins did not correlate to risk reduction. In fact, those who took 1 to 75 percent of prescribed statin levels showed more benefit in terms of cancer mortality risk than those who took more. We need a better-designed trial to determine whether there is really an effect.

Another study, a meta-analysis of 13 observational studies, showed that statins may play a role in reducing the risk of esophageal cancer. This is important, since esophageal cancer, especially adenocarcinoma that develops from Barrett’s esophagus, is on the rise. The results showed a 28 percent risk reduction in this type of cancer. The authors of the study surmise that statins may have a protective effect (2).

Although there is an association, these results need to be confirmed with randomized controlled trials. Aspirin has about the same 30 percent reduction in colorectal cancer, yet is not recommended solely for this use because of side effects.

Eye disease studies: mixed results

In two common eye diseases, glaucoma and cataracts, statins have vastly different results. In one study, statins were shown to decrease the risk of glaucoma by five percent over one year and nine percent over two years (3). It is encouraging that the longer the duration of statin use, the greater the positive effect on preventing glaucoma.

Statins also help to slow glaucoma progression in patients suspected of having early-stage disease at about the same rate. This was a retrospective study analyzing statin use with patients at risk for open-angle glaucoma. We need prospective (forward-looking) studies. With cataracts, it is a completely different story. Statins increase the risk of cataracts by over 50 percent, as shown in the Waterloo Eye Study (4). Statins exacerbate the risk of cataracts in an already high-risk group, diabetes patients.

Quality of life and longevity studies: a mixed bag

In a meta-analysis involving 11 randomized controlled trials, statins did not reduce the risk of all-cause mortality in moderate to high-risk primary prevention participants (5). This study analysis involved over 65,000 participants with high cholesterol and at significant risk for heart disease.

However, in this same study, participants at high risk for coronary heart disease saw a substantial improvement in their quality of life with statins. In other words, the risk of a nonfatal heart attack was reduced by more than half and nonfatal strokes by almost half, avoiding the potentially disabling effects of these events.

Fatigue side-effect study

Some of my patients who are on statins complain of fatigue. A randomized controlled trial published in the Archives of Internal Medicine reinforces the idea that statins increase the possibility of fatigue (6).

Women, especially, complained of lower energy levels, both overall and on exertion, when they were blindly assigned to a statin-taking group. The trial had three groups: two that took statins, simvastatin 20 mg and pravastatin 40 mg; and a placebo group. The participants were at least 20 years old and had LDL (bad) cholesterol of 115 to 190 mg/dl, with less than 100 mg/dl considered ideal.

In conclusion, some individuals who are at high risk for cardiovascular disease may need a statin, but it is likely that statins are overprescribed in primary prevention. Evidence of the best results points to lifestyle modifications, including diet and exercise shifts, with or without statins.

References: 

(1) N Engl J Med 2012;367:1792-1802. (2) Clin Gastroenterol Hepatol. 2013 Jun; 11(6):620–629. (3) Ophthalmology 2012;119(10):2074-2081. (4) Optom Vis Sci 2012;89:1165-1171. (5) Arch Intern Med 2010;170(12):1024-1031. (6) Arch Intern Med 2012;172(15):1180-1182.

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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Pixabay photo
The focus is on absorption and blood levels

By David Dunaief, M.D.

Dr. David Dunaief

With the recent storms, the cold temperatures and the not-quite-so-short, but still short days, it’s likely you’re not spending a lot of time outside in the sunshine with your skin exposed these days.

Here in the Northeast, this is the time of year when many reach for vitamin D supplements to compensate for a lack of vitamin D from the sun. Let’s explore what we know about vitamin D supplementation.

There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of a treatment paradigm. However, many questions remain.

At the 70th annual American Academy of Dermatology meeting in 2012, Dr. Richard Gallo, who was involved with the Institute of Medicine recommendations, shook things up by noting that, in most geographic locations, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water fatty fish, beef liver, and egg yolks. Most of us receive food-sourced vitamin D from fortified packaged foods, where vitamin D has been added.

We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular, autoimmune and skin diseases and cancer.

There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends between 20 and 50 ng/ml, and The Endocrine Society recommends at least 30 ng/ml.

Cardiovascular mixed results

Stock photo

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (1).

However, a small randomized controlled trial (RCT) called the cardioprotective effects of vitamin D into question (2). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2,500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study end points.

Most trials relating to vitamin D are observational, which provides associations, but not links. However, the VITAL study was a large, five-year RCT looking at the effects of vitamin D and omega-3s on cardiovascular disease and cancer (3). Study results were disappointing, finding that daily vitamin D3 supplementation at 2000 IUs did not reduce the incidence of cancers (prostate, breast or colorectal) or of major cardiovascular events.

Mortality decreased

In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: nine percent reduction with vitamin D plus calcium and seven percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

Weight benefit

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (4).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.

USPSTF recommendations

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (6). The supplement combination does not seem to reduce fractures, but does increase the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

When to supplement?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it might play an integral role with many disorders. But it is also important not to raise the levels too high. The range that I tell my patients is between 32 and 50 ng/ml, depending on their health circumstances.

References: 

(1) Circulation. 2008 Jan 29;117(4):503-511. (2) PLoS One. 2012;7(5):e36617. (3) NEJM. 2018 published online Nov. 10, 2018. (4) J Women’s Health (Larchmt). 2012 Jun 25. (5) J Clin Endocrinol Metabol. online May 17, 2012. (6) JAMA. 2018;319(15):1592-1599.

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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Make exercise a priority — part of the fabric of your life. METRO photo
In some circumstances, exercise may be as powerful as medications

By David Dunaief, M.D.

Dr. David Dunaief

Exercise has powerful effects in altering how our genes express themselves and can improve our outcomes with specific diseases. Exercise has effects on diabetes and a host of other chronic diseases, including kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Despite all the positives, it’s sometime difficult to motivate yourself to realize the benefits. There are, however, simple ways to motivate yourself during exercise. One study showed that those who repeated positive mantras to themselves while exercising were able to persist in their exercise routines for longer periods (2).

Why is this so important now? Because we are too sedentary, and this is the time of the year when we are especially so. According to data from the 2015-2016 National Health & Nutrition Examination Survey, we spend 6.4 hours a day sedentary (3). And this percentage is trending up.

Exercise can alter your genes

While you may be waiting for gene therapy to cure our chronic illnesses, it turns out that exercise may have a significant impact on our genes. No waiting required, this is here and now.

In a study, results showed that thousands upon thousands of genes in fat cells were affected when participants exercised (4). The study involved sedentary men and asked them to exercise twice a week at a one-hour spin class. 

According to the researchers, the genes impacted were those involved most likely in storing fat and in risk for subsequent diabetes and obesity development. Participants’ gene expression was altered by DNA methylation, the addition of a methyl group made up of a carbon and hydrogens. These participants also improved their biometrics, reducing fat and subsequently shrinking their waist circumferences, and improved their cholesterol and blood-pressure indices.

The effect is referred to as epigenetics, where lifestyle modifications can ultimately lead to changes in gene expression, turning them on and off. This has been shown with dietary changes, but this is one of the first studies to show that exercise also has significant impacts on our genes. It took only six months to see these numerous gene changes with modest amounts of cardiovascular exercise.

Do you need more encouragement? Another study showed substantial gene changes in muscle cells after one workout on a stationary bike (5). 

Is exercise as good as drug therapy?

We don’t think of exercise as being a drug, but what if it had similar benefits to certain drugs in cardiovascular diseases and mortality risk? A meta-analysis — a group of 57 studies that involved drugs and exercise — showed that exercise potentially has equivalent effects to statins in terms of mortality with secondary prevention of coronary heart disease (6). This means that, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same was true with pre-diabetes and the use of metformin vs. exercise. It didn’t matter which one was used, the drug or the lifestyle change.

Don’t change your medication without consulting your physician.

Reducing the risk of kidney stones

Anyone who has tried to pass a kidney stone knows it can be an excruciating experience. Most of the treatment revolves around pain medication, fluids and waiting for the stone to pass. However, the best way to treat kidney stones is to prevent them.

In the Women’s Health Initiative Observational Study, exercise reduced the risk of kidney stones by as much as 31 percent (7). Even better, the intensity of the exercise was irrelevant to its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results. But lesser amounts of exercise also saw substantial reductions. This study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones.

Does sex count as exercise?

We have heard that sex may be thought of as exercise, but is this myth or is there actual evidence? Try not to giggle. Well, it turns out this may be true. In a study published in the PLoS One journal, researchers found that young healthy couples exert 6 METs — metabolic energy, or the amount of oxygen consumed per kilogram per minute — during sexual activity (8).

How does this compare to other activities? Well, we exert about 1 MET while sitting and 8.5 METs while jogging. Sexual activity falls between walking and jogging, in terms of the energy utilized, and thus may be qualified as moderate activity. Men and women burned slightly less than half as many calories with sex as with jogging, burning a mean of 85 calories over about 25 minutes. Who says exercise can’t be fun?

I can’t stress the importance of exercise enough. It not only influences the way you feel, but also may influence gene expression and, ultimately, affects the development and prevention of disease. In certain circumstances, it may be as powerful as medications and, in combination, may pack a powerful punch. Therefore, make exercise a priority — part of the fabric of your life. It may already be impacting the fabric of your body: your genes.

References: 

(1) JAMA. 2009;301(19):2024. (2) Med Sci Sports Exerc. 2013 Oct 10. (3) JAMA Netw Open. 2019;2(7):e197597. (4) PLoS Genet. 2013 Jun;9(6):e1003572. (5) Cell Metab. 2012 Mar 7;15(3):405-11. (6) BMJ 2013; 347. (7) JASN online 2013, Dec. 12. (8) PLoS One 8(10): e79342.

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
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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