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Dr. David Dunaief

It is very important to stay hydrated and drink plenty of fluids, especially if you have a history of stone formation. METRO photo
Once you’ve had one stone, your risk for others increases

By David Dunaief, M.D.

Dr. David Dunaief

Kidney stones can have no symptoms, but more often they present with the classic symptoms of blood in the urine and colicky pain. This pain can be intermittent or constant, and it can range from dull to extremely painful, described by some as being worse than giving birth, shot or burned. The pain may radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1).

Stones are usually diagnosed through the symptoms and either abdominal x-rays or non-contrast CT scans.

Unfortunately, the first line treatment for passing kidney stones — at least small ones — involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are <4mm pass spontaneously. Location is an important factor as well, with stones closest to the opening of the urethra more likely to pass (2).

Generally, if you’ve passed a kidney stone, you know it. In the case of a stone too large to pass naturally, a urologist may use surgery, ultrasound, or a combination of methods to break it into smaller pieces, so it can be passed.

Unfortunately, once a patient forms one stone, the incidence of others increases significantly over time. The good news is that there are several lifestyle changes you can make to reduce your risk.

Hydrate, hydrate, hydrate

First, it is very important to stay hydrated and drink plenty of fluids, especially if you have a history of stone formation (3). You don’t have to rely on drinking lots of water to accomplish this. Increasing your consumption of fruits and vegetables that are moisture-filled can help, as well.

Calcium from diet vs. supplements

One of the simplest methods is to reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones. Calcium oxalate is the dominant one, occurring approximately 80 percent of the time (4). Calcium supplements, therefore, increase the risk of kidney stones. When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (5). According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (6). It did not matter whether participants were taking calcium citrate or calcium carbonate supplements.

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

Watch your sodium intake

It’s important to reduce sodium for many reasons, but we’ll provide one more here. Again, in the Nurses’ Health Study, participants who consumed 4.5 g sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 g per day (6). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Limit animal protein

Animal protein also may play a role. In a five-year, randomized clinical trial, men who reduced their consumption of animal protein to approximately two ounces per day, as well as lowering their sodium, were 51 percent less likely to experience a kidney stone than those who consumed a low-calcium diet (7). These were men who had a history of stone formation. The reason animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that animal protein’s higher sulfur content produces more acid. This acid is neutralized by release of calcium from the bone (8). That calcium can then promote kidney stones.

Reverse blood pressure naturally

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (9). Amazingly, it did not matter whether or not the patients were treated for high blood pressure with medications; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not just the symptoms.

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

References: 

(1) emedicine January 1, 2008. (2) J Urol. 2006;175(2):575. (3) J Urol. 1996;155(3):839. (4) N Engl J Med. 2004;350(7):684. (5) Kidney Int 2003;63:1817–23. (6) Ann Intern Med. 1997;126(7):497-504. (7) N Engl J Med. 2002 Jan 10;346(2):77-84. (8) J Clin Endocrinol Metab. 1988;66(1):140. (9) BMJ. 1990;300(6734):1234.

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.

High-fiber salads can help fight hemorrhoid pain. METRO photo
Simple methods to prevent constipation can help

By David Dunaief, M.D.

Dr. David Dunaief

For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms — and often say we “have hemorrhoids,” when we really mean our hemorrhoids are causing us pain.

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and childbirth. When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually bleed, especially during a bowel movement, which can be scary. Fortunately, hemorrhoids are not a harbinger of more serious disease.

There are two types of hemorrhoids: external, occurring outside the anus; and internal, occurring within the rectum.

When they are outside

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Because they can be self-treated, they generally do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet and supplementation (1). 

Sometimes, however, there is thrombosis (clotting) of external hemorrhoids. In these cases, they may become more painful and require medical treatment. If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should see your physician to make sure it is not due to a malignancy or other cause, such as inflammatory bowel disease.

When they are inside

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they are usually above the point of sensation in the colon, called the dentate line. If there is pain and discomfort, it’s generally because the internal hemorrhoids have falled out of place, due to weakening of the muscles and ligaments in the colon. This prolapse allows them to fall below the dentate line.

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

When issues are more severe

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

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

Preventing hemorrhoid problems

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

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

Increasing your fiber intake

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

Americans, on average, consume 16g per day of fiber (5). The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 to 38 grams, depending on gender and age (6). I typically recommend at least 40 grams. My wife and I try to eat only foods that contain a significant amount of fiber, and we consume approximately 65 grams a day.

You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned – side-effects are potentially gas and bloating for the first week or two.

References: 

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-6. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-7. (4) Dis Colon Rectum 2004 Aug;47(8):1364-70. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85.

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.

Symptoms of diverticular disease include fever and abdominal pain. METRO photo
Focusing on fiber can provide dramatic results

By David Dunaief, M.D.

Dr. David Dunaief

Diverticular disease, or diverticulosis, is a common malady that affects us as we age. Thirty-five percent of U.S. 50-year-olds are affected and, for those over the age of 60, approximately 58 percent are affected (1). The good news is that it is potentially preventable through modest lifestyle changes. Here, I will explain simple ways to reduce your risk, while also debunking a pervasive myth — that fiber, or more specifically nuts and seeds, exacerbates the disease.

What is diverticular disease? 

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

For those who experience symptoms, they may include fever and abdominal pain, predominantly in the left lower quadrant in Western countries, or the right lower quadrant in Asian countries. It may need to be treated with antibiotics.

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

Unfortunately, the incidence of diverticulitis is growing. As of 2010, about 200,000 are hospitalized for acute diverticulitis each year, and roughly 70,000 are hospitalized for diverticular bleeding (2). For those between 40 and 49 years old, the incidence of diverticulitis grew 132 percent between 1980 and 2007, the most recent data on this population (3).

How do you prevent diverticular disease and its complications? 

There are a number of modifiable risk factors, including diet composition, including fiber intake, along with weight and physical activity.

In a study that examined lifestyle risk factors for diverticulitis incidences, adhering to a low-risk lifestyle reduced diverticulitis risk almost 75 percent among men (4). The authors defined a low-risk lifestyle as including fewer than four servings of red meat a week, at least 23 grams of fiber a day, two hours of vigorous weekly activity, a body mass index of 18.5–24.9 kg/m2, and no history of smoking. They estimated that a low-risk lifestyle could prevent 50 percent of diverticulitis cases. 

Examining fiber’s effects

In terms of fiber, there was a prospective study published online in the British Medical Journal that extolled the value of fiber in reducing the risk of diverticular disease (5). This was part of the EPIC trial, involving over 47,000 people living in Scotland and England. The study showed a 31 percent reduction in risk in those who were vegetarian. 

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

Another study, which analyzed data from the Million Women Study, a large-scale, population-based prospective UK study of middle-aged women, confirmed the correlation between fiber intake and diverticular disease, and further analyzed the impact of different sources of fiber (6). The authors’ findings were that reduction in the risk of diverticular disease was greatest with high intake of cereal and fruit fiber.

Most Americans get about 16 grams of fiber per day. The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25-26 grams for women and 31-38 grams for men (7). Interestingly, their recommendations are lower for those who are over 50 years old.

Can you imagine what the effect is when people get at least 40 grams of fiber per day? This is what I recommend for my patients. Some foods that contain the most fiber include nuts, seeds, beans and legumes. In a 2009 study, those men who specifically consumed the most nuts and popcorn saw a protective effect from diverticulitis (8).

Obesity’s impact

In the large, prospective male Health Professionals Follow-up Study, body mass index played a significant role, as did waist circumference (9). Those who were obese (BMI >30 kg/m²) had a 78 percent increased risk of diverticulitis and a greater than threefold increased risk of a diverticular bleed compared to those who had a BMI in the normal range of <21 kg/m². For those whose waist circumference was in the highest group, they had a 56 percent increase risk of diverticulitis and a 96 percent increase risk of diverticular bleed. Thus, obesity puts patients at a much higher risk of diverticulosis complications.

Increasing physical activity

Physical activity is also important for reducing the risk of diverticular disease, although the exact mechanism is not yet understood. Regardless, the results are impressive. In a large prospective study, those with the greatest amount of exercise were 37 percent less likely to have diverticular disease compared to those with the least amount (10). Jogging and running seemed to have the most benefit. When the authors combined exercise with fiber intake, there was a dramatic 256 percent reduction in diverticular disease risk. 

Thus, if you are focused on preventing diverticular disease and its complications, lifestyle modifications may provide the greatest benefit.

References: 

(1) www.niddk.nih.gov. (2) Clin Gastroenterol Hepatol. 2016; 14(1): 96–103.e1. (3) Gastroenterology. 2019;156(5): 1282-1298. (4) Am J Gastroenterol. 2017; 112: 1868-1876. (5) BMJ. 2011; 343: d4131. (6) Gut. 2014 Sep; 63(9): 1450–1456. (7) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85. (8) AMA 2008; 300: 907-914. (9) Gastroenterology. 2009;136(1): 115. (10) Gut. 1995;36(2): 276.

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.

In the U.S., 24.4 million people over the age of 40 have cataracts. Pixabay photo
Reducing oxidative stress with diet may lower risk

By David Dunaief, M.D.

Dr. David Dunaief

The likelihood we will have cataracts that affect our vision increases as we age, but we can take an active role in preventing them. 

A cataract is an opacity or cloudiness of the lens in the eye, which decreases vision over time as it progresses. Typically, it’s caused by oxidative stress, and it’s common for both eyes to be affected.

Cataracts affect a substantial portion of the U.S. population. In the U.S., 24.4 million people over the age of 40 were afflicted, according to statistics gathered by the National Eye Institute of the National Institutes of Health (1). This number is expected to increase approximately 61 percent by the year 2030.

Cataract prevalence varies considerably by gender, with 61 percent of cases being women, and by race; 80 percent of those affected are white. There are many modifiable risk factors including diet, smoking, sunlight exposure, chronic diseases (such as diabetes and metabolic syndrome), steroid use, and physical inactivity. Here, we will focus on the dietary factor.

Impact of meat consumption on cataract risk

Diet has been shown to have substantial effect on the risk reduction for cataracts (2). One of the most expansive studies on cataract formation and diet was the Oxford (UK) group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

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

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

There really was not that much difference in meat consumption between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. This suggests that you can realize a meaningful effect by simply reducing or replacing your average meat intake, rather than eliminating meat from your diet.

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

Do antioxidants have an effect?

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

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

Among antioxidants studied that have shown positive effects is citrus. The Blue Mountains Eye Study found that participants who had the highest dietary intake of vitamin C reduced their 10-year risk for nuclear cataracts (4).

Cataract surgery

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

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage age-related macular degeneration (AMD) after cataract surgery (5). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients.

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

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

References: 

(1) nei.nih.gov. (2) Am J Clin Nutr. 2011 May; 93(5):1128-1135. (3) Exp Eye Res. 2007; 84: 229-245. (4) Am J Clin Nutr. 2008 Jun; 87(6):1899-1305. (5) Ophthalmology. 2003; 110(10):1960.

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.

High blood pressure can be lowered in part by exercise. METRO photo
Collaborate with your physician on lifestyle changes that improve risks

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension, also known as high blood pressure, is commanding a lot of attention in the U.S, where it’s pervasive, affecting approximately 45 percent of adults over 18 (1). Over the last decade, new and extended studies have given us better clarity about treatments, stratifying approaches to ensure the best outcomes for patients.

Since 2017, hypertension severity has been categorized into three stages, each with its recommended treatment regimen. One of the most interesting shifts with this recategorization was the recategorization of what we used to call “prehypertension” into what we now call “elevated” blood pressure and “hypertension stage 1.” 

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg, while Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of 80-89 mmHg (2). A simple chart of all levels can be found on The American Heart Association’s website at www.heart.org.

The consequences of both prehypertension and hypertension are significant, even though there are often no symptoms. For example, they increase the risk of cardiovascular disease and heart attack dramatically.

In an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (3). This is why it’s crucial to treat it in these early stages, even before it reaches the more severe levels of hypertension.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (4).

This can have a dramatic impact on quality of life.

Treating elevated blood pressure

In my view, it would be foolish not to treat elevated blood pressure. Updated recommendations for treatment, according to the Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, are lifestyle modifications (5).

Lifestyle changes include a Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet. It’s important to focus on fruits, vegetables, reduction in sodium to a maximum of 1500 mg (2/3 of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (6). Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (7). Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

The danger in treating elevated blood pressure comes only when medication is used, due to side effects. For example, the Trial of Preventing Hypertension (TROPHY), suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (8)(9). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Still, the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, the makers of the drug. 

In an editorial, Jay I. Meltze, M.D., a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (10). 

Elevated blood pressure is an asymptomatic disorder that has been shown to respond well to lifestyle changes — why create symptoms with medication? Therefore, I don’t recommend treating elevated blood pressure patients with medication. Thankfully, the JNC8 agrees.

Treating Stage 1 hypertension

For those with Stage 1 hypertension, but with a low 10-year risk of cardiovascular events, these same lifestyle modifications should be implemented for three-to-six months. At this point, a reassessment of risk and blood pressure should determine whether the patient should continue with lifestyle changes or needs to be treated with medications (11). It’s important to note that risk should be assessed by your physician. I am encouraged that the role of lifestyle modifications in controlling hypertension has been recognized. When patients and physicians collaborate on a lifestyle approach that drives improvements, the side effects are only better overall health.

References: 

 (1) cdc.gov. (2) heart.org. (3) Stroke 2005; 36: 1859–1863. (4) Hypertension 2006;47:410-414. (5) Am Fam Physician. 2014 Oct 1;90(7):503-504. (6) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (7) Archives of Internal Medicine 2001;161:589-593. (8) N Engl J Med. 2006;354:1685-1697. (9) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (10) Am J Hypertens. 2006;19:1098-1100. (11) Hypertension. 2021 Jun;77(6):e58-e67.

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.

Breads and rolls are loaded with sodium. METRO photo
Sauces, breads and soups are hidden sources of salt

By David Dunaief, M.D.

Dr. David Dunaief

All of us should be concerned about salt or, more specifically, our sodium intake, even if we don’t have high blood pressure. About 90 percent of Americans consume too much sodium (1).

Why does it matter?

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

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

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

How much is too much?

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

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

Where does sodium lurk?

Most of our sodium intake comes from processed foods, packaged foods and restaurants, not the salt shaker at home. There is nothing wrong with eating out or ordering in on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of her clothes and rings being tight.

Do you want to lose 5 to 10 pounds quickly? Decrease your salt intake. Excess sodium causes the body to retain fluids.

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon.

Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Make sure to read the labels on all packaged foods and sauces very carefully, checking for sodium and for serving size.

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

Soups are also notoriously high in sodium. There are a few packaged soups on the market that have no sodium, such as some Health Valley soups. Then, you can add your own seasonings.

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

Is sea salt better?

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

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

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

When seasoning your food at home, use salt-free seasonings, like Trader Joe’s 21 Seasoning Salute or, if you prefer a salty taste, use a salt substitute, like Benson’s Table Tasty.

References: 

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

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

Pixabay photo
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.

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. 

Pixabay photo
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. 

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.