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fiber

One can maintain regular bowel movement and lessen the risk of inflamed hemorrhoids by including more fiber in his or her diet, about 30 g per day. Stock photo
Most Americans don’t get enough fiber

By David Dunaief, M.D.

Dr. David Dunaief

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 child birth. 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. 

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 may scare most of us. Fortunately, hemorrhoids are not a harbinger of more serious disease. 

Treating external hemorrhoids

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. Thus, they can be self-treated and 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). However, sometimes there is thrombosis (clotting) of external hemorrhoids, in which case they may become more painful, requiring medical treatment.

Treating internal hemorrhoids

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 the hemorrhoids prolapse below this, there may be pain and discomfort, as well. Prolapse is when hemorrhoids fall out of place, due to weakening of the muscles and ligaments in the colon. 

The first step for treating internal hemorrhoids is to 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 was reduced dramatically (3).

There are several minimally invasive options, including anal banding, sclerotherapy and coagulation. The most effective of these is anal banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where two rubber bands are place at the neck of each hemorrhoid. 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.

How to prevent hemorrhoids

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.

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 12 g of fiber. 

Americans, on average, consume 16 g per day of fiber (5). For the average female or male between ages 31 and 50, the USDA recommends 25 and 30 g per day, respectively (6). I would recommend at least 40 g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65 g per 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.

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. 

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. The message throughout this article is that Americans need to get more fiber, which is beneficial for inflamed hemorrhoid prevention and treatment.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-456. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-1507. (4) Dis Colon Rectum 2004 Aug;47(8):1364-1370. (5) emedicine.com 2010. (6) health.gov. 

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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A diet high in fiber may help decrease the risk of heart disease, obesity and diabetes and has been linked to a lower incidence of some types of cancer. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Many people worry about getting enough protein, when they really should be concerned about getting enough fiber. 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 in the way that studies illustrate with fiber. 

As I mentioned in my previous article, Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily. 

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.

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 (1). 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 anti-oxidant effects of whole grains that are responsible for the positive results. 

Along the same lines of the respiratory findings, we 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 (2). 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.

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, a February 2004 irritable bowel syndrome (IBS) study (3). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

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 (4). 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 also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

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. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. 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 would recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased 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) Arch Intern Med. 2011;171(12):1061-1068. (2) Amer J Epidemiology 2008;167(5):570-578. (3) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (4) Amer J Clinical Nutrition 2009;90(3):664–671. 

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 suggests that drinking diet soda may increase the risk of heart disease. Stock photo
Simple dietary changes can improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Cardiovascular disease is anything but boring; what we know about it is constantly evolving. New information comes along all the time, which on the whole is a good thing. Even though cardiovascular disease has been on the decline, it is still the number one killer of Americans, responsible for almost 30 percent of deaths per year (1). However, not all studies nor all analyses on the topic are created equal. Therefore, I thought it apropos to present a quiz on cardiovascular disease myths and truths.

Without further ado, here is a challenge to your cardiovascular disease IQ. The questions below are either true or false. The answers and evidence are provided after.

1) Saturated fat is good for us, but processed foods and trans fats are unhealthy.

2) Fish oil supplements help reduce the risk of cardiovascular disease and mortality.

3) Fiber has significant beneficial effects on heart disease prevention.

4) Unlike sugary sodas and drinks, diet soda is most likely not a contributor to this disease.

5) Vitamin D deficiency may contribute to cardiovascular disease.

Now that was not so difficult. Or was it? The answers are as follows: 1-F, 2-F, 3-T, 4-F and 5-T. So, how did you do? Regardless of whether you know the answers, the reasons are even more important to know. Let’s look at the evidence.

Saturated fat

Most of the medical community has been under the impression that saturated fat is not good for us. We need to limit the amount we ingest to no more than 10 percent of our diet. But is this true? The results of a published meta-analysis (a group of 72 randomized clinical trials and observational studies) would upend this paradigm (2).

While saturated fat did not decrease the risk of cardiovascular disease, it did not significantly increase the risk either. Also, results showed that trans fats increase risk. Of course, trans fats are a processed fat, so this is something that most of us would agree upon. And in the clinical trials portion of the meta-analysis, omega-3 and omega-6 polyunsaturated fats did not significantly reduce the risk of cardiovascular disease.

Does this mean that we can go back to eating saturated fats with impunity? Well, there were weaknesses and flaws with this study. The authors only looked at the one dimension of fat. Their comparison was based on the upper-third of intake of one type of fat versus the lower-third of intake of the same type of fat (whether it was saturated fat or a type of unsaturated fat). It did not consider whether saturated fat was substituted with refined grains or unsaturated fatty acids. Also, what was the source of saturated fats, animal or plant, and did these sources also contain unsaturated fats as well, like olive oil or nuts which contain good fats?

Therefore, there are many unanswered questions and potentially several significant flaws with this study.

The meta-analysis also does not differentiate among plant or animal saturated fat sources. But in one that does, the researchers found saturated fats from animal sources increased cholesterol and the risk of cardiovascular disease (3). Also in another study, specifically using unsaturated fats in place of saturated fat reduced the risk of this disease (4, 5).

Fish oil

There is a whole industry built around fish oil and reducing the risk of cardiovascular disease. Yet the data don’t seem to confirm this theory. In the age-related eye disease study 2 (AREDS2), unfortunately, 1 gram of fish oil (long-chain omega-3 fatty acids) daily did not demonstrate any benefit in the prevention of cardiovascular disease nor its resultant mortality (6). This study was done over a five-year period in the elderly with macular degeneration. The cardiovascular primary end point was a tangential portion of the ophthalmic AREDS2. This does not mean that fish, itself, falls into that same category, but for now there does not seem to be a need to take fish oil supplements for heart disease, except potentially for those with very high triglycerides. Fish oil, at best, is controversial; at worst, it has no benefit with cardiovascular disease.

Fiber

We know that fiber tends to be important for a number of diseases, and cardiovascular disease does not appear to be an exception. In a meta-analysis involving 22 observational studies, the results showed a linear relationship between fiber intake and decreased risk for developing cardiovascular disease (7). In other words, for every 7 grams of fiber consumed, there was a 9 percent reduced risk in developing the disease. It did not matter the source of the fiber from plant foods; vegetables, grains and fruit all decreased the risk of cardiovascular disease. This did not involve supplemental fiber, like that found in Fiber One or Metamucil. To give you an idea about how easy it is to get a significant amount of fiber, one cup of lentils has 15.6 grams of fiber, one cup of raspberries or green peas has almost 9 grams, and one medium-size apple has 4.4 grams. Americans are sorely deficient in fiber (8).

Diet soda

A presentation at the American College of Cardiology examined the Women’s Health Initiative: The study suggests that diet soda may increase the risk of heart disease (9). In those drinking two or more cans per day, defined as 12 ounces per can, there was a 30 percent increased risk of a cardiovascular event, such as a stroke or heart attack, but an even greater risk of cardiovascular mortality, 50 percent, over 10 years. These results took into account confounding factors like smoking, diabetes, high blood pressure and obesity. This study involved over 56,000 postmenopausal women for almost a nine-year duration.

Vitamin D

The results of an observational study in the elderly suggest that vitamin D deficiency may be associated with cardiovascular disease risk. The study showed that those whose vitamin D levels were low had increased inflammation, demonstrated by elevated biomarkers including C-reactive protein (CRP) (10). This biomarker is related to inflammation of the heart, though it is not as specific as one would hope.

Beware in regards to saturated fat. If a study looks like an outlier or too good to be true, then probably it is. I would not run out and get a cheeseburger just yet. However, study after study has shown benefit with fiber. So if you want to reduce the risk of cardiovascular disease, consume as much whole food fiber as possible. Also, since we live in the Northeast, consider taking at least 1000 IUs of vitamin D daily. This is a simple way to help thwart the risk of the number one killer.

References:

(1) hhs.gov. (2) Ann Intern Med. 2014;160(6):398-406. (3) JAMA 1986;256(20):2623. (4) Am J Clin Nutr. 2009;99(5):1425-1432. (5) Cochrane Database Syst Rev. 2012:5;CD002137. (6) JAMA Intern Med. Online March 17, 2014. (7) BMJ 2013; 347:f6879. (8) Am J Med. 2013 Dec;126(12):1059-67.e1-4. (9) ACC Scientific Sessions 2014; Abstract 917-905. (10) J Clin Endocrinol Metab online February 24, 2014.

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 recent studies, whole fruit was shown to actually reduce the risk of type 2 diabetes.
Some surprising results about lifestyle

By David Dunaief, M.D.

Most of us know that type 2 diabetes is an epidemic in America and continues to grow. Type 2 diabetes was thought to be an adult-onset disease, but more and more children and adolescents are affected as well. The most recent statistics show that 50 percent of teens with diabetes between the ages of 15 and 19 have type 2 (1). Thus, this disease is pervasive throughout the population.

Let’s test our diabetes IQ. See if you can determine whether the following items are true or false.

•Whole fruit should be limited or avoided.

•Soy has detrimental effects with diabetes.

•Plant fiber provides too many carbohydrates.

•Coffee consumption contributes to diabetes.

•Bariatric surgery is an alternative to lifestyle changes.

My goal is to help debunk type 2 diabetes myths. All of these statements are false. Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has always been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (2). In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (3).

In yet another study, researchers looked at different whole fruits to determine their impacts on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (4) — that’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe. Fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

We know fiber is important in a host of diseases, and it is not any different in diabetes. In the Nurses’ Health Study and NHS II, two very large prospective (forward-looking) observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (5). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors therefore encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include: flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (6). The researchers could not determine which plants contributed the most benefit. They believe the effect is from antioxidant activity.

Soy and kidney function

Soy sometimes has a negative association. However, in diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (7). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

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

This is very important since diabetes patient are 20 to 40 times more likely to develop nephropathy than those without diabetes (8). It appears that soy protein may put substantially less stress on the kidneys than animal protein. This negative effect with animal protein may be due to higher levels of phosphorus. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

Coffee

Coffee is a staple in America and in my household. It is one thing my wife would never let me consider taking away. Well, she and the rest of the coffee-drinking portion of the country can breathe a big sigh of relief when it comes to diabetes.

There is a meta-analysis (involving 28 prospective studies) that shows coffee decreases the risk of developing diabetes (9). It was a dose-dependent effect; two cups decreased the risk more than one cup. Interestingly, it did not matter whether it contained caffeine or was decaffeinated. This suggests that caffeine is not necessarily the driving force behind the effect of coffee on diabetes.

The authors surmise that other compounds, including lignans, which have antioxidant effects, may play an important role. The duration of the studies ranged from 10 months to 20 years, and the database was searched from 1966 to 2013, with over one million participants.

Bariatric surgery

In recent years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery (involving 16 RCTs and observational studies), the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (10). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

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

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home messages are: Don’t avoid whole fruit; soy is potentially valuable; fiber from plants may play a very powerful role in preventing and treating diabetes; and coffee may help prevent diabetes.

Thus, the overarching theme is that you can’t necessarily go wrong with a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to increase the likely durability over 10 or more years.

References: (1) JAMA. 2007;297:2716-2724. (2) Nutr J. 2013 Mar. 5;12:29. (3) Am J Clin Nutr. 2012 Apr.;95:925-933. (4) BMJ online 2013 Aug. 29. (5) Diabetes Care. online 2014 Feb. 18. (6) Br J Nutr. 2005;93:393–402. (7) Diabetes Care. 2008;31:648-654. (8) N Engl J Med. 1993;328:1676–1685. (9) Diabetes Care. 2014;37:569-586. (10) Obes Surg. 2014;24:437-455.

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.

By David Dunaief, M.D.

Autoimmune diseases are becoming increasingly common, affecting approximately 23.5 million Americans, with 78 percent of them women. These numbers are expected to continue rising. There are more than 80 conditions with autoimmunity implications (1). These diseases include rheumatoid arthritis (RA), lupus, thyroid (hypo and hyper), psoriasis, multiple sclerosis and inflammatory bowel disease, to mention just a few.

Dr. David Dunaief

Autoimmune diseases are defined by the immune system inappropriately attacking organs, cells and tissues of the body, causing chronic inflammation. Thus, inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). In other words, once you have one, you are much more likely to acquire others.

Drug treatments

The mainstay of treatment is immunosuppressives. For example, in RA where there is swelling of joints bilaterally, the typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies are thought to help reduce the underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. The disease-modifying antirheumatic drugs (DMARDs) may slow or stop the progression of joint destruction and increase physical functioning. Remicade reduces C-reactive protein (CRP), a biomarker of inflammation.

However, there are several concerning factors with these drugs. First, the side effect profile is substantial. It includes the risk of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections. It is no surprise that suppressing the immune system would result in increased infection rates. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term randomized clinical trials, but many patients are put on these therapies for 20 or more years. Remicade’s package insert was approved with approximately two years of data.

So what other methods are available to treat autoimmune diseases? These include medical nutrition therapy using bioactive compounds, which have immunomodulatory (regulation of the immune system) effects on inflammatory factors and on gene expression, and supplementation.

Nutrition and inflammation

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. In one study, participants drank the equivalent of about one glass of freshly squeezed orange juice a day with a resultant 49 percent risk reduction in the development of RA (5).

While I have not found studies that specifically tested diet in RA treatment, there are dietary studies that have shown anti-inflammatory effects in other diseases, using biomarkers such as CRP and TNF-alpha. In a study that looked at the Mediterranean-type diet in 112 older patients, there was a significant decrease in inflammatory markers, including CRP (6).

In another study, participants showed a substantial reduction in CRP with increased flavonoid levels, an antioxidant, from vegetables and apples. Astaxanthin, a carotenoid found in fish, was shown to significantly reduce a host of inflammatory factors in mice, including TNF-alpha (7).

Vitamin D

Vitamin D is ubiquitous in helping to treat and prevent many chronic diseases — autoimmune diseases are no exception. Vitamin D affects over 200 genes, according to Wellcome Trust Centre for Human Genetics at University of Oxford. In the absence of vitamin D, T-cell response, part of the immune system, becomes dysfunctional and uncontrollable, resulting in an increase in multiple sclerosis (MS) and inflammatory bowel disease — Crohn’s and ulcerative colitis. However, when normal levels of vitamin D are conveyed to the vitamin D receptors, proper T-cell functioning is restored with no subsequent autoimmune disease, at least in animal studies (8).

Interestingly, multiple sclerosis patients are notoriously very low in vitamin D, and it is difficult to raise the levels. There was a small study proclaiming that MS patients may need as much as 50,000 IUs of vitamin D2 weekly, and that it was safe (9). I would check with a neurologist specializing in MS before taking such a high dose.

Fish oil

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry.

If you think vitamin D is impressive, fish oil affects as many as 1,040 genes (10). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory affects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory, such as NFkB.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (11). When treating patients with autoimmune disease, I typically suggest about 2 grams of EPA plus DHA to help regulate their immune systems. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood thinning effects.

Probiotic supplements

The gut contains approximately 70 percent of your immune system. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (12, 13).

In a study with Crohn’s disease patients, Lactobacillus casei and L. bulgaricus reduced the inflammatory factor, TNF-alpha (14). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Fiber

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (15).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha. (16).

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

References: (1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Am J Clin Nutr. 2005 Aug; 82(2):451-455. (6) Am J Clin Nutr. 2009 Jan;89(1):248-256. (7) Chem Biol Interact. 2011 May 20. (8) Prog Biophys Mol Biol. 2006 Sept;92(1):60-64. (9) Am J Clin Nutr. 2007 Sep;86(3):645-651. (10) Am J Clin Nutr. 2009 Aug;90(2):415-424. (11) Drugs. 2003;63(9):845-853. (12) Gut. 2003 Jul;52(7):975-980. (13) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (14) Gut. 2002;51(5):659. (15) Arch Intern Med. 2007;167(5):502-506. (16) Nutr Metab (Lond). 2010 May 13;7:42.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

Consuming white fleshy fruits such as pears may decrease ischemic stroke risk by as much as 52 percent.

By David Dunaief, M.D.

Stroke remains one of the top five causes of mortality and morbidity in the United States (1). As a result, we have a wealth of studies that inform us on issues ranging from identifying chronic diseases that increase stroke risk to examining the roles of medications and lifestyle in managing risk.

Impact of chronic diseases

There are several studies that show chronic diseases — such as age-related macular degeneration, rheumatoid arthritis and migraine with aura — increase the risk for stroke. Therefore, patients with these diseases must be monitored.

In the ARIC study, stroke risk was approximately 50 percent greater in patients who had AMD compared to those who did not — 7.6 percent versus 4.9 percent, respectively (2). This increase was seen in both types of stroke: ischemic (complete blockage of blood flow in the brain) and hemorrhagic (bleeding in the brain). The risk was greater for hemorrhagic stroke than for ischemic, 2.64 vs. 1.42 times increased risk.

However, there was a smaller overall number of hemorrhagic strokes, which may have skewed the results. This was a 13-year observational study involving 591 patients, ages 45 to 64, who were diagnosed with AMD. Most patients had early AMD. If you have AMD, you should be followed closely by both an ophthalmologist and a primary care physician.

Rheumatoid arthritis (RA)

In an observational study, patients with RA had a 30 percent increased risk of stroke, and those under 50 years old with RA had a threefold elevated risk (3). This study involved 18,247 patients followed for a 13-year period. There was also a 40 percent increased risk of atrial fibrillation (AF), a type of arrhythmia or irregular heartbeat. Generally, AF causes increased stroke risk; however, the authors were not sure if AF contributed to the increased risk of stroke seen here. They suggested checking regularly for AF in RA patients, and they surmised that inflammation may be an underlying cause for the higher number of stroke events.

Migraine with aura

In the Women’s Health Study, an observational study, the risk of stroke increased twofold in women who had migraine with aura (4). Only about 20 percent of migraines include an aura, and the incidence of stroke in this population is still rather rare, so put this in context (5).

Medications with beneficial effects

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (6). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (7).

It is important to recognize that chronic disease increases stroke risk. High blood pressure and high cholesterol are two of the most significant risk factors. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Medication combination: negative impact

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (8, 9).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day — an adult dose — it would result in 900,000 major bleeding events per year (10).

Lifestyle modifications

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (11). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (12). The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s important role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (13). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — low-dose aspirin — since the risk of a second stroke is high.

References: (1) cdc.gov. (2) Stroke online April 2012. (3) BMJ 2012; Mar 8;344:e1257. (4) Neurology 2008 Aug 12; 71:505. (5) Neurology. 2009;73(8):576. (6) AAN conference: April 2012. (7) Am J Cardiol 2012; 109(9):1308-1314. (8) ISC 2012; Abstract LB 9-4504; (9) www.clinicaltrials.gov NCT00059306. (10) JAMA 2007;297:2018-2024. (11) Stroke. 2011; 42: 3190-3195. (12) J. Nutr. 2011;141(8):1552-1558. (13) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

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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