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Exercise

Being active is the magic pill for a healthy life. Stock photo
Inactivity may increase mortality and disease risk

By David Dunaief, M.D.

Dr. David Dunaief

With the advent of summer weather, with its heat and humidity, who wants to think about exercise? Instead, it’s tempting to lounge by the pool or even inside with air conditioning.

First, let me delineate between exercise and inactivity; they are not complete opposites. When we consider exercise, studies tend to focus on moderate to intense activity. However, light activity and being sedentary, or inactive, tend to get clumped together. But there are differences between light activity and inactivity.

Light activity may involve cooking, writing and strolling (1). Inactivity involves sitting, as in watching TV or in front of a computer screen. Inactivity utilizes between 1 and 1.5 metabolic equivalent units — better known as METS — a way of measuring energy. Light activity, however, requires greater than 1.5 METS. Thus, in order to avoid inactivity, we don’t have to exercise in the dreaded heat. We need to increase our movement.

What are the potential costs of inactivity? According to the World Health Organization, over 3 million people die annually from inactivity. This ranks inactivity in the top five of potential underlying mortality causes (2).

How much time do we spend inactive? In an observational study of over 7,000 women with a mean age of 71 years old, 9.7 waking hours were spent inactive or sedentary. These women wore an accelerometer to measure movements. Interestingly, as body mass index and age increased, the amount of time spent sedentary also increased (3).

Inactivity may increase the risk of mortality and plays a role in increasing risks for diseases such as heart disease, diabetes and fibromyalgia. It can also increase the risk of disability in older adults.

Surprisingly, inactivity may be worse for us than smoking and obesity. For example, there can be a doubling of the risk for diabetes in those who sit for long periods of time, compared to those who sit the least (4).

Let’s look at the evidence.

Does exercise overcome inactivity?

We tend to think that exercise trumps all; if you exercise, you can eat what you want and, by definition, you’re not sedentary. Right? Not exactly. Diet is important, and you can still be sedentary, even if you exercise. In a meta-analysis — a group of 47 studies — results show that there is an increased risk of all-cause mortality with inactivity, even in those who exercised (5). In other words, even if you exercise, you can’t sit for the rest of the day. The risk for all-cause mortality was 24 percent overall.

However, those who exercised saw a blunted effect with all-cause mortality, making it significantly lower than those who were inactive and did very little exercise: 16 percent versus 46 percent increased risk of all-cause mortality. So, it isn’t that exercise is not important, it just may not be enough to reduce the risk of all-cause mortality if you are inactive for a significant part of the rest of the day.

Worse than obesity?

Obesity is a massive problem in this country; it has been declared a disease, itself, and it also contributes to other chronic diseases. But would you believe that inactivity has more of an impact than even obesity? In an observational study, using data from the EPIC trial, inactivity might be responsible for two times as many premature deaths as obesity (6). This was a study involving 330,000 men and women.

Interestingly, the researchers created an index that combined occupational activity with recreational activity. They found that the greatest reduction in premature deaths (in the range of 16 to 30 percent) was between two groups, the normal weight and moderately inactive group versus the normal weight and completely inactive group. The latter was defined as those having a desk job with no additional physical activity. To go from the completely inactive to moderately inactive, all it took, according to the study, was 20 minutes of brisk walking on a daily basis.

So what have we learned about inactivity? If you are inactive, increasing your activity to be moderately inactive by briskly walking for 20 minutes a day may reduce your risk of premature death significantly. Even if you exercise the recommended 150 minutes a week, but are inactive the rest of the day, you may still be at risk for cardiovascular disease. You can potentially further reduce your risk of cardiovascular disease by increasing your activity with small additions throughout the day.

The underlying message is that we need to consciously move throughout the day, whether at work with a walk during lunch or at home with recreational activity. Those with desk jobs need to be most attuned to opportunities to increase activity. Simply setting a timer and standing or walking every 30 to 45 minutes may increase your activity levels and possibly reduce your risk.

References:

(1) Exerc Sport Sci Rev. 2008;36(4):173-178. (2) WHO report: http://bit.ly/1z7TBAF. (3) JAMA. 2013;310(23):2562-2563. (4) Diabetologia 2012; 55:2895-2905. (5) Ann Intern Med. 2015;162:123-132, 146-147. (6) Am J Clin Nutr. online Jan. 24, 2015.

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

In a recent study, those who watched at least six hours of TV per day during their lifetime had a decrease in longevity of 4.8 years. Stock photo
Television viewing can lower your physical and mental health

By David Dunaief, M.D.

Dr. David Dunaief

According to the Nielsen Company, Americans spend an average of 10½ hours per day watching programming of some kind, whether on a television, computer or a portable device (1). For our purposes, we’ll call this TV, because most is consumed while sitting, although the average watching modality has shifted considerably.

What impact does all this watching have on our lives? It may be hazardous to your health. I know this seems obvious, but bear with me. The extent of the effect is surprising. According to 2013 Netflix research, binge-watching, or watching more than two or more episodes of a single program in a row, is perceived as providing a refuge from our busy lives. This also has an addictive effect, prompting dopamine surges as we watch. Interestingly, it also can lead to postbinge depression when a show ends and to isolation and lower social interaction while viewing (2).

TV’s detrimental effect extends beyond the psychological, potentially increasing the risk of heart attacks, diabetes, depression, obesity and even decreasing or stunting longevity. My mother was right when she discouraged us from watching television, but I don’t think even she knew the extent of its impact.

Cardiovascular events including heart attacks 

There was a very interesting observational study published in the New England Journal of Medicine that showed watching sporting events increases the risk of heart attacks and other cardiovascular events, such as arrhythmia (irregular heartbeat) and unstable angina (severe chest pain ultimately due to lack of oxygen). The researchers followed Germans who watched the FIFA (soccer) World Cup playoffs in 1996. 

How much did watching increase the risk of cardiovascular events? This depended on what round of the playoffs and how close a game it was. The later the round and the closer the game, the greater the risk of cardiovascular events. Knockout games, which were single elimination, seemed to have the greatest impact on cardiovascular risk. When Germany was knocked out in the semifinals, the finals between France and Italy did not have any cardiovascular effect. 

Overall, men experienced a greater than threefold increase in risk, while women experienced an increased risk that was slightly below twofold. According to the authors, it was not the outcome of the game that mattered most, but the intensity. The study population involved 4,279 German residents in and around the Munich area (3). 

Another study found that, compared to fewer than two hours a day, those who watched four or more hours experienced an increased risk of cardiovascular disease mortality of 80 percent. I know this sounds like a lot of TV, but remember that the average daily American viewing time is significantly over this. This study, called the Australian Diabetes, Obesity, and Lifestyle study (AusDiab) was observational, looking at 8,800 adults over a six-year period (4). 

Impact on life expectancy 

The adage that life tends to pass you by when you watch TV has a literal component. An observational study found that TV may reduce the life expectancy of viewers. In the study, those who watched at least six hours per day during their lifetime had a decrease in longevity of 4.8 years. However, this is not the whole story. What is even more telling is that after the age of 25, for every hour of TV, one might expect to potentially lose 21.8 minutes of life expectancy (5). According to the authors, these results rival those for obesity and sedentary lifestyles.

Diabetes and obesity risk

In the Nurses’ Health Study, for every two hours of television viewing on a daily basis there were increased risks of type 2 diabetes and obesity of 23 and 14 percent, respectively (6). The results show that sitting at work for two hours at a time increased the risk of diabetes and obesity by only 5 and 7 percent, respectively, much less of an effect than TV watching. The authors surmise that we can reduce the incidence of diabetes and obesity by 43 and 30 percent, respectively, by cutting our TV time by 10 hours a week.

Modestly reducing the amount of television is a simple lifestyle modification that can have a tremendous impact on longevity, quality of life and prevention of the top chronic disease. So, step away from your television, tablet or computer and get out in the world.

References:

(1) Nielsen.com (2) nbcnews.com/better/health/what-happens-your-brain-when-you-binge-watch-tv-series-ncna816991. (3) N Engl J Med 2008; 358:475-483. (4) Circulation. 2010 Jan 26;121(3):384-391. (5) Br J Sports Med doi:10.1136/bjsm.2011.085662. (6) JAMA. 2003 Apr 9;289(14):1785-1791.

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

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Anthony Amen, back middle, with his emplyees at Redefine Fitness in Mount Sinai. Photo from Anthony Amen

Helping people and seeing the positive impacts on their lives is the best part of the job for Anthony Amen, the owner of Redefine Fitness in Mount Sinai. 

“There’s nothing better than that,” he said. 

Though for Amen, his path to opening his new business last fall started almost a decade ago when he was a sophomore in college at SUNY Oswego.  

It was there in February 2010 when Amen was playing broomball, a game played on ice in a similar way to hockey, but instead of a stick it’s done with a rubber-headed broom, and instead of skates players wear rubber-soled shoes. He was playing with his friends, but his life changed when a friendly game took a turn for the worse.

Anthony Amen after his injury in 2010. Photo from Amen

“We were playing a game and a friend of mine went in for a slide tackle,” he said. “I was trying to avoid the hit and slipped, fell backwards and whacked my head on the ice very hard.”

Amen suffered a serious concussion, along with injuries to his neck and back. For three-and-a-half months he was unable to look at any visible light and sat in his bed in the dark for much of the time.  

As a result of his head injury, Amen began suffering from debilitating migraines. He could barely move his head and he was unable to put his hands above his head. 

He said sought help from doctors, but each told him that concussions take time to recover from, and it was something he would have to learn to deal with. 

“I went to 25 different doctors and they all told me the same thing — ‘There’s nothing wrong with you. We can’t do anything,’” Amen said. “They put me on Percocet and muscle relaxants and told me ‘Good luck.’”

He said a doctor told him he was “a physician, not a magician. I don’t know what you want from me.”

It was those experiences that served as the catalyst that would change Amen’s life. 

Amen said he was stubborn, and he didn’t want to give up and didn’t want this to be his norm. 

“I started experimenting and working out in the gym to try to make myself better,” he said. “The more I did the better I felt.”

The Mount Sinai business owner said he was able to fix himself from getting migraines every week and being unable to get out of bed, to never having one in more than five years. 

“One of the biggest moments for me was being able to put my hands over my head again,” he said. 

Amen works on a fitness ball at his gym. Photo from Amen

Amen fell in love with fitness and wanted to teach people what he had learned. He began working at various gyms throughout Long Island as a trainer and in management, with a goal to eventually own a place of his own. A year-and-a-half ago, his vision became a reality when he decided he would open Redefine Fitness. 

“It was very stressful to open a business, but I was passionate about this and I had to try,” he said. ”I think it was the right time for me to try. I have no wife and kids — I didn’t want to regret not doing this.”  

In fall 2018, Redefine Fitness opened its doors with one of the goals of making the connection between fitness, medicine and rehabilitation. They use research-based information in conjunction with their certified trainers to make tailored workout programs for their clients. 

Amen admits the first few months open have gone better than he could have ever imagined.  

“The clients have been so great, they tell me they see the passion in me,” he said. 

One experience that sticks out to Amen was when he trained a 65-year-old woman who had a lung transplant and had a breathing machine. He said she would struggle to tie her own shoes. 

“We got her to squat 175 pounds and got her to run,” he said. “It was amazing seeing this woman’s life change from being told you couldn’t do something. It shows that if you put your mind to something you could achieve anything.”

The Mount Sinai gym has five trainers, including Amen, and offers one-on-one training sessions, weight loss programs and various classes as well as special needs and post-rehab programs. 

In the future, Amen hopes to expand the gym to other locations, and wants to continue making a positive impact in the community.  

Reflecting to his pre-college days, Amen said he was not the athlete type and used to run 15-minute miles and be happy about it. 

“Looking back I would’ve never pictured this in a million years,” he said. “I want to show [people] that there’s no giving up. I want to pass that knowledge and passion to everybody else.”

Exercising 30 minutes four to five times a week is best. Stock photo
It is possible to overdo exercise for weight loss purposes

By David Dunaief, M.D.

Dr. David Dunaief

When we make a New Year’s resolution to exercise regularly, the goal is often either to change body composition, to lose weight, or at least to maintain weight. How much exercise is best for these purposes? It is a hotly debated topic. You would think the answer would be straightforward, since exercise helps us prevent and resolve a great many diseases.

At the same time, we hope exercise impacts our weight. Does it? It is important to manage our expectations, before we start exercising. There are some intriguing studies that address whether exercise has an impact on weight management. The short answer is yes; however, not always in ways we might expect.

Then the questions become: What type of exercise should we be doing? How frequently and for how long? Let’s look at the evidence.

Duration

It makes sense that the more we exercise to lose weight, the better, or at least that is what we thought. In a small randomized controlled trial (RCT), the gold standard of studies, results showed that the moderate group in terms of duration saw the most benefit for weight loss (1). 

There were three groups in the study — a sedentary group (low), a group that did 30 minutes per day of aerobic exercise (moderate) and a group that did 60 minutes per day of aerobic exercise (high).

Perhaps obviously, the sedentary group did not see a change in weight. Surprisingly, though, the group that did 30 minutes of exercise per day experienced not only significantly more weight loss than the sedentary group, but also more than the 60-minute exercise group. The aerobic exercises involved biking, jogging or other perspiring activities. These were healthy young men that were overweight, but not obese, and the study duration was three months.

The authors surmise that the reason for these results is that the moderate group may have garnered more energy and moved around more during the remainder of the day, as sensors showed. The highest exercise group was sedentary through most of the rest of day, probably due to fatigue. Also, it seemed that the highest exercise group ate more than the moderate group, though the difference was not statistically significant. While this study is of impressive quality, it is small and of short duration. Nonetheless, its results are encouraging.

Postmenopausal women

As a group, postmenopausal women have considerable difficulty losing weight and maintaining weight loss. In a secondary analysis of a randomized controlled trial, there were three aerobic exercise groups differentiated by the number of kcal/kg per week they burned: 4, 8 and 12 (2). All of the groups saw significant reductions in waist circumference. Interestingly, however, a greater number of steps per day outside of the training, measured by pedometer, were primarily responsible for improved waistline circumference, regardless of the intensity of the workouts.

But it gets more intriguing, because the group that exercised with the lowest intensity was the only one to see significant weight loss. More is not always better, and in the case of exercise for weight loss, less may be more. This study reinforces the suppositions made by the authors of the previous men’s study: We should exercise to a point where it is energy inducing and not beyond.

Premenopausal women

Not to ignore younger women, those who were premenopausal also saw a significant benefit with weight maintenance and exercise after having intentionally lost weight.

In a prospective (forward-looking) study, young women who did at least 30 minutes of exercise four to five days per week were significantly less likely to regain weight that they had lost, compared to those who were sedentary after losing weight (3).

Some of the strengths of this study were its substantially long six-year follow-up period and its large size, involving over 4,000 women between the ages of 26 and 45. Running and jogging were more impactful in preventing weight gain than walking with alacrity. However, all forms of exercise were superior to the sedentary group.

Aerobic exercise and resistance training

In another RCT with 119 overweight or obese adults, aerobic exercise four to five times a week for about 30 minutes each was most effective for weight loss and fat reduction, while resistance training added lean body mass. Lean body mass is very important. It does not cause weight reduction, but rather increased fitness (4).

With weight loss, it’s important to delineate between thin and fit. Fitness includes a body composition of decreased body fat and increased lean muscle mass. To help achieve fit level, it’s probably best to have a combination of aerobic and anaerobic exercise (resistance training). Both contribute to achieving this goal.

In conclusion, exercise can play a significant role in weight, whether with weight reduction, weight maintenance or increasing lean body mass. It appears that 30 minutes of exercise four to five times a week is best. Longer is not necessarily better.

What is most important, however, is to exercise to the point where it energizes you, but doesn’t cause fatigue. This is because it is important not to be sedentary the rest of the day, but to remain active. We should also include a complete package of lifestyle modifications in general — diet, exercise and stress reduction — to get the most compelling results.

References:

(1) Am J Physiol Regul Integr Comp Physiol. 2012 Sep 15;303(6):R571-R579. (2) Am J Prev Med. 2012;43(6):629-635. (3) Obesity 2010;18(1):167-174. (4) J Appl Physiol. 2012 Dec;113(12):1831-1837.

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

٭We invite you to check out our weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

Placing one foot in front of the other can lead to impressive mental and physical benefits. Stock photo
Benefits are seen with modest exercise

By Dr. David Dunaief

Dr. David Dunaief

There is great emphasis on exercise. We have heard it is good for us ever since we were children in gym class striving for the presidential fitness award. 

The average reaction, unfortunately, is an aversion to exercise. As kids, many of us tried to get out of gym class, and as adults, we “want” to exercise, but we “don’t have time.” The result of this is a nation of couch potatoes. I once heard that the couch is the worst deep-fried food. It perpetuates inactivity, especially when watching TV. Even sleeping burns more calories.

I think part of the problem is that we don’t know what type of exercise is best and how long and frequently to do it. 

Well, guess what? There is an easy way to get tremendous benefit with very little time involved. You don’t need expensive equipment, and you don’t have to join a gym. You can sharpen your wits with your feet.

Jane Brody has written in The New York Times’ Science Times about Esther Tuttle. Esther was 99 years old, sharp as a tack and was independently mobile, with no aids needed. She continued to stay active by walking in the morning for 30 minutes and then walking again in the afternoon. The skeptic might say that this is a nice story, but its value is anecdotal at best. 

Well, evidence-based medicine backs up her claim that walking is a rudimentary and simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away. 

Walking has a powerful effect on preserving brain function and even growing certain areas of the brain (1). Walking between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years.

Those participants who had an increase in brain tissue volume had a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants who had a mean age of 78 and were dementia free at the start of the trial. Imagine if you started earlier? 

In yet another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2). 

Even better news is that, if you’re pressed for time or if you’re building up your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile? You’ll be surprised at how much better you will  feel — and how much sharper your thinking is.

If you ratchet up the exercise to running, a study showed that mood improves, mollifying anger (3). The act of running actually increases your serotonin levels, a hormone that, when low, can make people agitated or angry. So exercise may actually help you get your aggressions out.

Walking has other benefits as well. We’ve all heard about the importance of doing weight-bearing exercise to prevent osteoporosis and osteoporotic fractures. The movie “WALL-E” even did a spoof on this, projecting a future where people lived in their movable recliners. The result was a human skeletal structure that had receded over the generations from lack of use. Although it was tongue in cheek, it wasn’t too far from the truth; if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles. 

So remember, use your feet to keep your mind sharp. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References: 

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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

We invite you to check out our new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.

Sound Beach resident Todd Leighley’s mustache is freckled with gray and his face shows lines of age, but he doesn’t mind. Though his left leg was amputated below the knee after a motorcycle crash in 2009, and now he wears a thick carbon fiber prosthetic, all that matters to him is that he continue the sports he played as a kid, namely skating. He has embarked on a mission to try to get a skate park built in his community.

“I’m fat, middle aged and one legged, and I’m having the time of my life,” Leighley said.

For the past four years Leighley, the 47-year-old emergency services specialist for public electric company Public Service Enterprise Group, has been advocating for the construction of a skate park in the Sound Beach area, which he hopes to call Hawks Nest All Wheel Park. What he has in mind is something to help those kids in the area who aren’t keen to participate in the usual team sports.

“Skateboarding is looked down upon — it’s not embraced and supported like football and lacrosse,” the skateboarder said. “The parks are coming, and they can’t keep fighting it forever.”

When he was 6 years old Leighley said he learned to love skating. He became mired in a culture that conveys freedom: freedom of expression, freedom from problems, freedom to go where you want. His appreciation for the culture deepened when he moved to Hawaii in his 20s and became involved in the surfing scene. It was a continuous part of his life until 2009 when he was involved in a motorcycle crash, suffering compound fractures in his femur, tibia and fibula. The leg had to be removed, and he did not know if he could continue with all his favorite sports from his childhood.

It was around the time shortly after the accident he said he learned, in the Brooklyn Bike Park, which was a different type of skate park, of something called a “pump track,” where riders build momentum through the up and down motion of wheels on a track with several ups and downs, either with a bike or skateboard.

“It’s like a roller coaster, but instead of a roller coaster that would use machinery to pull carts up hill, here you’re using your muscles,” Leighley said. “You’re pumping and using it to get speed. It tricks you into using your muscles.”

He said that type of skate park revitalized his lifelong passion for skating. The transcendent experience of boarding around the block is something he said he wants his community to feel.

While the skater exudes passion from every pore, Leighley has had trouble generating the right type of interest for the project from the community. While there are multiple mountain bike trails in the area and the Shoreham BMX track right behind the Robert S. Reid Community Center, there are very few options for a skateboarder other than sidewalks and roadways, not unless they want to travel many miles to either Riverhead, Amityville or Huntington.

Joseph Mannix, a Copiague social studies teacher, is also a community leader when it comes to the Huntington skateboarding community and has walked the steps Leighley is trying to follow. As a veteran skater who has been boarding since “the clay wheel days” of the 1970s, he is the one chiefly responsible for the East Northport Veterans Park Skate Park. It was built after years of working with his community, starting with skating lessons that eventually built up into clubs and a driving interest of local children, adults and eventually support from the town.

“At [the Greenlawn Skate Park] I started a lessons program and summer camp which became so successful that the town got interested, and they saw how much revenue they were making and how healthy it was,” Mannix said. “I was pushing for those kids who are not so into organized sports, or kids into organized sports who want the personal experience of skateboarding.”

While those parks remain popular, Leighley said he believes a park filled with transitions, pools and quarter pipes can only apply to 20 percent of adrenaline sports enthusiasts because of how daunting they seem to a newcomer. He said a pump track can apply to people of any skill level since riders can take any path at their own pace.

Port Jefferson resident Rachel Whalen, 30, a friend of Leighley’s, said she just got back into skating about seven months ago, and as a single mother raising two children, she wants to have a place near her home where she can exercise along with her kids.

“I would use it, I would want my kids to use it to,” Whalen said.

Despite the setbacks in trying to get the project off the ground, the Sound Beach resident said he has become closer to his community through his skate park campaign. Leighley became involved with the North Shore Youth Council, where executive director of the organization Janene Gentile said he teaches local kids basics in martial arts. While Gentile sees him as a caring man, she said others in the community have been unnerved by his classic skater-rebellion style personality.

“[Leighley] has the personality of a very radical dude, and while he’s trying to temper it, some people get taken aback,” Gentile said. “He’s a radical dude, but he’s caring, compassionate and passionate about his vision.”

Skateboarders agree that tenacity is the foundation of the sport. As long as one keeps at learning a trick, despite its difficulty, eventually any technique can be learned. It’s why Leighley said he will not be giving up on his vision any time soon.

“Kids need hope,” he said. “They need these things, they need these lifelines to pull them up.”

Pedometers can be the first step to helping those with mild COPD. Stock photo
Lifestyle changes can reduce COPD exacerbations

By David Dunaief, M.D.

Dr. David Dunaief

COPD, or chronic obstructive pulmonary disease, is the third leading cause of mortality in the United States (1), although it’s not highlighted much in the layman’s press.

COPD is an umbrella term that includes emphysema, chronic bronchitis of more than three months for two consecutive years and/or chronic obstructive asthma. It is an obstructive lung disease that limits airflow. The three most common symptoms of the disease involve shortness of breath, especially on exertion, production of sputum and cough. This disease affects 6.7 percent of the U.S. population (2).

It tends to be progressive, meaning more frequent and severe exacerbations over time. Since it is a devastating and debilitating chronic disease with no cure, anything that can identify and prevent COPD exacerbations, as well as comorbidities (associated diseases), is critically important.

What are the traditional ways to reduce the risk of and treat COPD exacerbations? The most important step is to stop smoking, since 80 percent of COPD is related to smoking. Supplemental oxygen therapy and medications, such as corticosteroids, bronchodilators (beta-adrenergic agonists and anticholinergics) and antibiotics help to alleviate symptoms (3).

One of the underlying components of COPD may be chronic inflammation (4). Therefore, reducing inflammation may help to stem COPD exacerbations. There are several inflammatory biomarkers that could potentially help predict exacerbations and mortality associated with this disease, such as interleukin-6 (IL-6), C-reactive protein (CRP), leukocyte (white blood cell) count and fibrinogen (a clotting factor of the blood).

How do we reduce inflammation, which may contribute to exacerbations of this disease? Some drugs, such as statins, work partially by reducing inflammation. They may have a role in COPD. Lifestyle changes that include a high-nutrient, anti-inflammatory diet and exercise may also be beneficial. Let’s look at the evidence.

Biomarkers for inflammation

In a recent population-based study with over 60,000 participants, results show that as three biomarkers (CRP, leukocyte count and fibrinogen) were elevated, the risk of COPD exacerbation increased in a linear manner (5). In other words, the risk of frequent exacerbation increased 20, 70 and 270 percent within the first year as the number of elevated biomarkers increased from one to three, compared to patients who did not have biomarker elevations.

As time progressed beyond the first year of follow-up, risk exacerbation continued to stay high. Patients with all three biomarkers elevated for longer periods had a 150 percent increased risk of frequent exacerbations. These predictions were applicable to patients with stable and with mild COPD.

In an observational study, results showed that when the biomarker IL-6 was elevated at the start of the trial in stable COPD patients, the risk of mortality increased almost 2.7-fold (6). Also, after three years, IL-6 increased significantly. Elevated IL-6 was associated with a worsening of six-minute walking distance, a parameter tied to poor physical performance in COPD patients. However, unlike the previous study, CRP did not show correlation with increased COPD exacerbation risk. This was a small trial, only involving 53 patients. Therefore, the results are preliminary.

These biomarker trials are exciting for their potential to shape treatments based on level of exacerbation risk and mortality, creating more individualized therapies. Their results need to be confirmed in a randomized controlled trial (RCT). Many of these biomarkers mentioned in the two trials are identifiable with simple blood tests at major labs.

Statin effect

Statins have been maligned for their side effects, but their efficacy has been their strong suit. An observational trial showed that statins led to at least a 30 percent reduction in the risk of COPD exacerbations, with the effect based on a dose-dependent curve (7). In other words, as the dose increased, so did the benefit.

Interestingly, even those who had taken the statin previously saw a significant reduction in COPD exacerbation risk. The duration of statin use was not important; a short use of statins, whether presently or previously, had substantial benefit. 

However, the greatest benefit was seen in those who had been on a medium to high dose or were on the drug currently. The researchers believe that the mechanism of action for statins in this setting has to do with their anti-inflammatory and immune-modulating effects. This was a retrospective (backward-looking) study with over 14,000 participants. We will need a prospective (forward-looking) study and an RCT to confirm the results.

Exercise

Pedometers can be the first step to helping those with mild COPD. Stock photo

Exercise is beneficial for almost every circumstance, and COPD is no exception. But did you know that a pedometer might improve results? In a three-month study, those with mild COPD were much more successful at achieving exercise goals and reducing exacerbations and symptoms when they used pedometers, compared to the group given advice alone (8). Pedometers gave patients objective feedback on their level of physical activity, which helped motivate them to achieve the goal of walking 9,000 steps daily. This is a relatively easy way to achieve exercise goals and reduce the risk of COPD exacerbations.

When exercising, we are told to vary our exercise routines on a regular basis. One study demonstrates that this may be especially important for COPD patients (9). Results show that nonlinear periodization exercise (NLPE) training is better than traditional routines of endurance and resistance training in severe COPD patients. The goal of NLPE is to alter the time spent working out, the number of sets, the number of repetitions and the intensity of the workout on a regular basis.

This study was randomized, involved 110 patients and was three months in duration. Significantly more severe COPD patients achieved their exercise goals using NLPE rather than the traditional approach. The group that used NLPE also had an improved quality of life response. The researchers believe that compliance with an NLPE-type program is mostly likely going to be greater because patients seem to enjoy it more.

Chronic inflammation may play a central role in COPD exacerbation. Nonspecific inflammatory biomarkers are potentially valuable for providing a more personalized approach to therapy. Drugs that can control inflammation, such as statins, show promise. But don’t forget the importance of lifestyle changes, such as quitting smoking and committing to an exercise regimen that is varied and/or involves the use of a pedometer. And potentially a high-nutrient, anti-inflammatory diet will also contribute positively to reducing the frequency and severity of COPD exacerbations.

References:

(1) Natl Vital Stat Rep. 2011 Dec.;59(10):1-126. (2) cdc.gov. (3) N Engl J Med. 2002;346:988-994. (4) www.goldcopd.org. (5) JAMA. 2013;309:2353-2361. (6) Respiratory Research. 2013;14:24. (7) Am J Med. 2013 Jul;126:598-606. (8) ATS 2013 International Conference: Abstract A1360. (9) Am J Respir Crit Care Med. 2013; online Feb. 28.

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

As you become more active, Santa, you’ll find that you have more energy all year round, not just on Christmas Eve.

By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

This time of year, people around the world are no doubt sending you lists of things they want through emails, blogs, tweets and old-fashioned letters. In the spirit of giving, I’d like to offer you — and maybe your reindeer — some advice.

Let’s face it: You aren’t exactly the model of good health. Think about the example you’re setting for all those people whose faces light up when they imagine you shimmying down their chimneys. You have what I’d describe as an abnormally high BMI (body mass index). To put it bluntly, you’re not just fat, you’re obese. Since you are a role model to millions, this sends the wrong message.

We already have an epidemic of overweight kids, leading to an ever increasing number of type 2 diabetics at younger and younger ages. According to the Centers for Disease Control and Prevention, as of 2015, more than 100 million U.S. adults are living with diabetes or prediabetes. It complicates the issue that approximately two-thirds of the U.S. population is overweight and/or obese. This is just one of many reasons we need you as a shining beacon of health.

Obesity has a much higher risk of shortening a person’s life span, not to mention quality of life and self-image. The most dangerous type of obesity is an increase in visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if a waistline, measured from the navel, is greater than or equal to 40 inches for a man, and is greater than or equal to 35 inches for a woman. The chances of diseases such as pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is a chance for you to lead by example (and, maybe, by summer, to fit into those skinny jeans you hide in the back of your closet). Think of the advantages to you of being slimmer and trimmer. For one thing, Santa, you would be so much more efficient if you were fit. Studies show that with a plant-based diet, focusing on fruits and vegetables, people can reverse atherosclerosis, clogging of the arteries.

The importance of a good diet not only helps you lose weight but avoid strokes, heart attacks, peripheral vascular diseases, etc. But you don’t have to be vegetarian; you just have to increase your fruits, vegetables and whole-grain foods significantly. With a simple change, like eating a handful of raw nuts a day, you can reduce your risk of heart disease by half. Santa, future generations need you. Losing weight will also change your center of gravity, so your belly doesn’t pull you forward. This will make it easier for you to keep your balance on those steep, icy rooftops.

Exercise will help, as well. Maybe for the first continent or so, you might want to consider walking or jogging alongside the sleigh. As you exercise, you’ll start to tighten your abs and slowly see fat disappear from your midsection, reducing risk and practicing preventive medicine. Your fans everywhere leave you cookies and milk when you deliver presents. It’s a tough cycle to break, but break it you must. You — and your fans — need to see a healthier Santa. You might let slip that the modern Santa enjoys fruits, especially berries, and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in humus, which have substantial antioxidant qualities and can help reverse disease.

As for your loyal fans, you could place fitness videos under the tree. In fact, you and your elves could make workout videos for those of us who need them, and we could follow along as you showed us “12 Days of Workouts with Santa and Friends.” Who knows, you might become a modern version of Jane Fonda or Richard Simmons or even the next Shaun T!

How about giving athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games? You could even give wearable devices that track step counts and bike routes or stuff gift certificates for dance lessons into people’s stockings. These might influence the recipients to be more active.

By doing all this, you might also have the kind of energy that will make it easier for you to steal a base or two in this season’s North Pole Athletic League’s Softball Team. The elves don’t even bother holding you on base anymore, do they?

As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll find yourself parking the sleigh farther away and skipping from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Think about something much closer to home, even. Your reindeer won’t have to work so hard. You might also fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!

Wishing you good health in the new year,

David

P.S. I could really use a new baseball bat, if you have a little extra room in your sleigh.

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

A recent study found that those who walk with more pace are more likely to decrease their mortality from all causes and increase their longevity.
Look beyond the number of steps you take
Dr. David Dunaief

By David Dunaief, M.D.

For most of us, exercise is not a priority during the winter months, especially during the holiday season. We think that it’s okay to let ourselves go and that a few more pounds will help insulate us from the anticipated cold weather, when we will lock ourselves indoors and hibernate. Of course I am exaggerating, but I am trying to make a point. During the winter, it is even more important to put exercise at the forefront of our consciousness, because we tend to gain the most weight during the Thanksgiving to New Year holiday season (1).

Many times we are told by the medical community to exercise, which of course is sage advice. It seems simple enough; however, the type, intensity level and frequency of exercise may not be well defined. For instance, any type of walking is beneficial, right? Well, as one study that quantifies walking pace notes, some types of walking are better than others, although physical activity is always a good thing compared to being sedentary.

We know exercise is beneficial for prevention and treatment of chronic disease. But another very important aspect of exercise is the impact it has on specific diseases, such as diabetes and osteoarthritis. Also, certain supplements and drugs may decrease the beneficial effects of exercise. They are not necessarily the ones you think. They include resveratrol and nonsteroidal anti-inflammatory drugs (such as ibuprofen). Let’s look at the evidence.

Walking with a spring in your step

While pedometers give a sense of how many steps you take on a daily basis, more than just this number is important. Intensity, rather than quantity or distance, may be the primary indicator of the benefit derived from walking.

In the National Walkers’ Health Study, results showed that those who walk with more pace are more likely to decrease their mortality from all causes and to increase their longevity (2). This is one of the first studies to quantify specific speed and its impact. In the study, there were four groups. The fastest group was almost jogging, walking at a mean pace of less than 13.5 minutes per mile, while the slowest group was walking at a pace of 17 minutes or more per mile.

The slowest walkers had a higher probability of dying, especially from dementia and heart disease. Those in the slowest group stratified even further: Those whose pace equaled 24-minute miles or greater had twice the risk of death compared to those who walked with greater speed. However, the most intriguing aspect of the study was that there were big differences in mortality reduction in the second slowest category compared to the slowest, which might only be separated by a minute-per-mile pace. So don’t fret: You don’t have to be a speed walker in order to get significant benefit.

Mind-body connection

The mind also plays a significant role in exercise. When we exercise, we tend to beat ourselves up mentally because we are disappointed with our results. The results of a new study say that this is not the best approach (3). Researchers created two groups. The first was told to find four positive phrases, chosen by the participants, to motivate them while on a stationary bike and repeat these phrases consistently for the next two weeks while exercising.

Members of the group who repeated these motivating phrases consistently, throughout each workout, were able to increase their stamina for intensive exercise after only two weeks, while the same could not be said for the control group, which did not use reinforcing phrases.

‘Longevity’ supplement may have negative impact

Resveratrol is a substance that is thought to provide increased longevity through proteins called Sirtuin 1. So how could it negate some benefit from exercise? Well, it turns out that we need acute inflammation to achieve some exercise benefits, and resveratrol has anti-inflammatory effects. Acute inflammation is short-term inflammation and is different from chronic inflammation, which is the basis for many diseases.

In a small randomized controlled study, treatment group participants were given 250 mg supplements of resveratrol and saw significantly less benefit from aerobic exercise over an eight-week period, compared to those who were in the control group (4). Participants in the control group had improvements in both cholesterol and blood pressure that were not seen in the treatment group. This was a small study of short duration, although it was well designed.

Impact on diabetes complications

Unfortunately, type 2 diabetes is on the rise, and the majority of these patients suffer from cardiovascular disease. Drugs used to control sugar levels don’t seem to impact the risk for developing cardiovascular disease.

So what can be done? In a recent prospective (forward-looking) observational study, results show that diabetes patients who exercise less frequently, once or twice a week for 30 minutes, are at a higher risk of developing cardiovascular disease and almost a 70 percent greater risk of dying from it than those who exercised at least three times a week for 30 minutes each session. In addition, those who exercised only twice a week had an almost 50 percent increased risk of all-cause mortality (5). The study followed more than 15,000 men and women with a mean age of 60 for five years. The authors stressed the importance of exercise and its role in reducing diabetes complications.

Fitness age

You can now calculate your fitness age without the use of a treadmill, according to the HUNT study [6]. A new online calculator utilizes basic parameters such as age, gender, height, weight, waist circumference and frequency and intensity of exercise, allowing you to judge where you stand with exercise health. This calculator can be found at www.ntnu.edu/cerg/vo2max. The results may surprise you.

Even in winter, you can walk and talk yourself to improved health by increasing your intensity while repeating positive phrases that help you overcome premature exhaustion. Frequency is important as well. Exercise can also have a significant impact on complications of chronic diseases, such as cardiovascular disease and resulting death with diabetes.

When the weather does become colder, take caution when walking outside to avoid black ice or use a treadmill to walk with alacrity. Getting outside during the day may also help you avoid the winter blues.

References: (1) N Engl J Med. 2000;342:861-867. (2) PLoS One. 2013;8:e81098. (3) Med Sci Sports Exerc. 2013 Oct. 10. (4) J Physiol Online. 2013 July 22. (5) Eur J Prev Cardiol Online. 2013 Nov. 13. (6) Med Sci Sports Exerc. 2011;43:2024-2030.

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

Taking a 20-minute power walk at lunchtime has numerous health benefits. Stock photo
Are activity and exercise the same?

By David Dunaief, M.D.

Dr. David Dunaief

Let’s begin with a pretest. I want to make it clear that a pretest is not to check whether you know the information but that you have an open mind and are willing to learn.

1) Which may have the most detrimental impact on your health?

a.   Smoking

b.   Obesity

c.   Inactivity

d.   A and C

e.   All have the same impact

2) People who exercise are considered active.

a.   True

b.   False

3) Inactivity may increase the risk of what? Select all that apply.

a.   Diabetes

b.   Heart disease

c.   Fibromyalgia

d.   Mortality

e.   Disability

With the recent wave of heat and humidity, who wants to think about exercise? Instead, it’s tempting to lounge by the pool or even inside with air conditioning instead.

First, let me delineate between exercise and inactivity; they are not complete opposites. When we consider exercise, studies tend to focus on moderate to intense activity. However, light activity and being sedentary, or inactive, tend to get clumped together. But there are differences between light activity and inactivity.

Light activity may involve cooking, writing, and strolling (1). Inactivity involves sitting, as in watching TV or in front of a computer screen. Inactivity utilizes between 1 and 1.5 metabolic equivalent units — better known as METS — a way of measuring energy. Light activity, however, requires greater than 1.5 METS. Thus, in order to avoid inactivity, we don’t have to exercise in the dreaded heat. We need to increase our movement.

What are the potential costs of inactivity? According to the World Health Organization, over 3 million people die annually from inactivity. This ranks inactivity in the top five of potential underlying mortality causes (2). The consequences of inactivity are estimated at 1 to 2.6 percent of health care dollars. This sounds small, but it translates into actual dollars spent in the U.S. of between $38 billion and $100 billion (3).

How much time do we spend inactive? Good question. In an observational study of over 7,000 women with a mean age of 71 years old, 9.7 waking hours were spent inactive or sedentary. These women wore an accelerometer to measure movements. Interestingly, as BMI and age increased, the amount of time spent sedentary also increased (4).

Inactivity may increase the risk of mortality and plays a role in increasing risks for diseases such as heart disease, diabetes and fibromyalgia. It can also increase the risk of disability in older adults.

Surprisingly, inactivity may be worse for us than smoking and obesity. For example, there can be a doubling of the risk for diabetes in those who sit for long periods of time, compared to those who sit the least (5).

By the way, the answers to the pretest are 1) e; 2) b; 3) a, b, c, d and e.

Let’s look at the evidence.

Does exercise trump inactivity?

We tend to think that exercise trumps all; if you exercise, you can eat what you want and, by definition, you’re not sedentary. Right? Not exactly. Diet is important, and you can still be sedentary, even if you exercise. In a meta-analysis — a group of 47 studies — results show that there is an increased risk of all-cause mortality with inactivity, even in those who exercised (6). In other words, even if you exercise, you can’t sit for the rest of the day. The risk for all-cause mortality was 24 percent overall.

However, those who exercised saw a blunted effect with all-cause mortality, making it significantly lower than those who were inactive and did very little exercise: 16 percent versus 46 percent increased risk of all-cause mortality. So, it isn’t that exercise is not important, it just may not be enough to reduce the risk of all-cause mortality if you are inactive for a significant part of the rest of the day.

In an earlier published study using the Women’s Health Initiative, results showed that those who were inactive most of the time had greater risk of cardiovascular disease (7). Even those who exercised moderately but sat most of the day were at increased risk of cardiovascular disease. Moderate exercise was defined as 150 minutes of exercise per week. Those at highest risk were women who did not exercise and sat at least 10 hours a day. This group had a 63 percent increased risk of cardiovascular disease (heart disease or stroke).

However, those who sat fewer than five hours a day had a significantly lower risk of cardiovascular events. And those who were in the highest group for regular exercise (walking seven hours/week or jogging/running four to five hours/week) did see more benefit in cardiovascular health, even if they were inactive the rest of the day. Sitting longer did not have a negative impact on the individuals in the high exercise level group.

Worse than obesity?

Obesity is a massive problem in this country; it has been declared a disease, itself, and it also contributes to other chronic diseases. But would you believe that inactivity has more of an impact than even obesity? In an observational study, using data from the EPIC trial, inactivity might be responsible for two times as many premature deaths as obesity (8). This was a study involving 330,000 men and women.

Interestingly, the researchers created an index that combined occupational activity with recreational activity. They found that the greatest reduction in premature deaths (in the range of 16 to 30 percent) was between two groups, the normal weight and moderately inactive group versus the normal weight and completely inactive group. The latter was defined as those having a desk job with no additional physical activity. To go from the completely inactive to moderately inactive, all it took, according to the study, was 20 minutes of brisk walking on a daily basis.

All is not lost!

In another study, which evaluated 56 participants, walking during lunchtime at work immediately improved mood (9). This small study clearly shows that by lunchtime activity changed mood for the better, increasing enthusiasm and reducing stress when compared to morning levels, before participants had walked. Participants had to walk at least 30 minutes three times a week for 10 weeks; pace was not important.

So what have we learned thus far about inactivity? It is all relative. If you are inactive, increasing your activity to be moderately inactive by briskly walking for 20 minutes a day may reduce your risk of premature death significantly. Even if you exercise the recommended 150 minutes a week, but are inactive the rest of the day, you may still be at risk for cardiovascular disease. You can potentially further reduce your risk of cardiovascular disease by increasing your activity with small additions throughout the day.

The underlying message is that we need to consciously move throughout the day, whether at work with a walk during lunch or at home with recreational activity. Those with desk jobs need to be most attuned to opportunities to increase activity. Simply setting a timer and standing or walking every 30 to 45 minutes may increase your activity levels and possibly reduce your risk.

References: (1) Exerc Sport Sci Rev. 2008;36(4):173-178. (2) WHO report: http://bit.ly/1z7TBAF. (3) forbes.com. (4) JAMA. 2013;310(23):2562-2563. (5) Diabetologia 2012; 55:2895-2905. (6) Ann Intern Med. 2015;162:123-132, 146-147. (7) J Am Coll Cardiol. 2013;61(23):2346-2354. (8) Am J Clin Nutr. online Jan. 24, 2015. (9) Scand J Med Sci Sports. Online Jan. 6, 2015.

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

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