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Health

BOE approved changes in 2017, slow transition to full compliance to continue into ’18-19 school year

A BOE policy is increasing healthy food options in PJ schools. Stock photo from Metro

Port Jefferson School District is looking to become a healthier place.

Students and parents returning this fall should expect to see further changes to foods offered in cafeterias, sold for team and club fundraisers, and even those foods allowed at school celebrations for the 2018-19 year to meet standards set in a May 2017 board of education policy change.

In a July letter addressed to parents from Danielle Turner, the now-departed district director of health, physical education and athletics, the policy was enacted to address nutritional concerns as well as increase students’ physical activity throughout the school day, a move designed to keep the district in line with state and federal regulations.

“Elements of the policy went into effect last year,” Superintendent Paul Casciano said. “We chose a path of gradual compliance starting with last year so our students and advisers could plan accordingly going into the 2018-19 school year.”

Under the policy, school meals in the district now must include fruits, vegetables, salads, whole grains and low-fat items, adherent to federal standards. In addition, food and beverages sold in vending machines and school stores must meet nutrition standards set by federal regulations. Food and beverages sold by clubs and teams for fundraisers, both on school grounds and off, will also be subject to the same regulations. The policy also impacts in school celebrations and parties where food and drinks are provided, saying building principals will “encourage” parents and staff to follow the guidelines, and restricts the use of food “as
an incentive or reward for instructional purposes.”

“As a school community, it is important that we model what we teach about health,” Casciano said.

Student body president and Port Jefferson senior Reid Biondo said clubs and teams were made aware the policy change was coming last year and started to make preparations to adhere to the changes when it comes to fundraising.

“The fundraisers are very important for clubs and teams,” he said. “Not being able to fundraise by selling food is a source of concern but the students at Earl L. Vandermeulen are very creative and are already coming up with solutions. Last year, one of the classes hosted a volleyball tournament in place of a bake sale. There are plenty of alternatives to bake sales but students and teams are going to need to work a little harder for their money.”

Despite the challenges created by the policy, Biondo said he sees the district’s point of view in trying to foster a healthier school environment.

“I think they are right to encourage a more healthy lifestyle and I think it is a step in the right direction,” he said. “Students should have access to healthy eating options and that part of this change in the school district excites me. However, I do not think removing the unhealthy choices entirely is the solution.”

Biondo pointed out that CVS is less than a five-minute walk from the school’s front door, and he suspects many of his peers will go there to purchase an unhealthy after-school snack. This would mean the revenue from bake or candy bar sale would be going to an outside source, while students continue making unhealthy choices. The senior also suggested the district should provide additional education about healthy lifestyle choices and consuming snacks in moderation, to encourage students to lead a healthy lifestyle in and outside of school.

Casciano said the district took the fundraising obstacles for extracurricular organizations into account when crafting the policy and suggested healthier alternatives can still be sold to raise money. He added the district’s hiring of Adam Sherrard to take over for Turner will have no bearing on the implementation of the policy.

The full board wellness policy can be found at www.portjeffschools.org under “Community” tab.

Plastic presents a difficult but necessary to address challenge for the world's oceans. Photo courtesy of United States Coast Guard

By Herb Herman

“The charmed ocean’s pausing, the waves lie still and gleaming, and the lulled winds seem dreaming,” wrote Lord Byron, an 18th-century British poet.

Yet is our ocean, in which scientists estimated in 2014 that there are 5.25 trillion pieces of plastic debris, still charmed? Of that, 269,000 tons float on the surface, while some 4 billion plastic microfibers per square kilometer litter the deep sea. The United Nations estimated in 2006 every square mile of ocean contains 46,000 pieces of floating plastic. According to a University of Georgia study, about 19 billion pounds of plastic trash winds up in our oceans each year.

Durability is one of plastic’s chief properties, which is the reason plastics present a seemingly endless threat to the marine environment. And the oceans are not the only repository of pollutants. Approximately 40 percent of the lakes in America are too polluted for fishing, aquatic life, or swimming. More than 1 million seabirds and 100,000 sea mammals are killed by plastic pollution every year.

One of the main culprits of this high level of ocean, lake and river pollution is from industrial sources, an abundant source of plastics in various forms. Further contributors to pollution are municipalities’ garbage, a significant quantity of which ends up in our waterways. But boaters are not by any means innocent. Virtually all boaters have plastic bottles, Styrofoam cups, plastic wrappers and more onboard. Much of this detritus finds its way overboard instead of into designated garbage bags, which should be removed when departing a boat. Remember, plastics are not degradable. And while plastic bags and other items may be labeled as biodegradable, in most cases they will only break down at temperatures over 50 degrees Celsius, a temperature not normally reached in the ocean.

Hurricane Irma resulted in an enormous number of fiberglass boat wrecks in the Florida Keys. In an effort to clean up after the hurricane, many of the boats were crushed, giving off fiberglass particulates. This airborne pollutant made many people ill, to the extent that a number of residents had to be hospitalized. There is no acceptable way to recycle fiberglass, although means for doing just that are widely sought.

Further, plastic microparticles less than 5 millimeters in size, have shown up in the stomachs of marine life. These particles can be consumed by humans, causing still not clearly understood health problems, although it is believed these toxins can cause cancer and stunt the growth of fetuses. The U.N. has further recognized the possibility of these plastic microparticles acting as vehicles for transporting diseases such as Zika and Ebola from animals to humans.

So, you might ask, why bother us, the boating public with these lectures about keeping the trash in the boat and disposing of it responsibly? It might seem that boats contribute a marginal amount of pollution. However, for example, during an average summer, Port Jefferson Harbor has almost 600 resident boats and some 6,000 transients and is a busy cruising destination from May through October. One can imagine the amount of plastic pollution this number of boats could contribute to this beautiful body of water.

“Take it with you” should be emblazoned on all boaters’ minds.

Herb Herman is the public affairs officer for the USCG Auxiliary Port Jefferson Flotilla 014-22-06. He is a distinguished professor emeritus at Stony Brook University.

Preventing diabetes, cancer and stroke

By David Dunaief, M.D.

Dr. David Dunaief

What better way than a season centered around eating al fresco to kick-start you on the path to preventing chronic diseases? In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are foods commonly found at barbecues and picnic meals. Therefore, I think it is only fair to talk about healthier alternatives and the evidence-based medicine that supports their benefits.

The Mediterranean-style diet is the key to success. It is composed of thousands of beneficial nutrients that interact with each other in a synergistic way. This particular diet, as I have mentioned in previous articles, includes fish, green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of olive oil. We all want to be healthier, but doesn’t healthy mean tasteless? Not necessarily.

At a memorable family barbecue, we had a bevy of choices that were absolutely succulent. These included a three-bean salad, mandarin orange salad with raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon filets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable and scallop shish kebobs and a large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence.

Cancer studies

Fruits and vegetables may help prevent pancreatic cancer. This is very important, since by the time there are symptoms, the cancer has spread to other organs and the patient usually has less than 2.7 years to live (1). Five-year survival is only 5 percent (2). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and noncitrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (3). Interestingly, cooked vegetables, not just raw ones, had a substantial effect. 

Garlic plays an important role in reducing the risk of colon cancer. In the IOWA Women’s Health Study, a large prospective (forward-looking) trial involving 41,837 women, there was a 32 percent reduction in risk of colon cancer for the highest intake of garlic compared to the lowest. Vegetables also showed a statistically significant reduction in the disease as well (4). Many of my patients find that fresh garlic provides a wonderful flavor when cooking vegetables.

Diabetes studies — treatment and prevention

Fish plays an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of intake of fish and seafood had a substanttial decrease in risk of Type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood in potentially preventing the disease. Therefore, there is nothing wrong with shrimp on the “barbie” to help protect you from developing diabetes. 

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial (the gold standard of studies), mixed nuts led to a substantial reduction of hemoglobin A1c, a very important biomarker for sugar levels for the past three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease. The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke 

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial. Though these are promising results, I would caution use no more than one tablespoon of olive oil per day, since there are 120 calories in a tablespoon. 

It is not difficult to substitute the valuable Mediterranean-style diet for processed meats or at least add them to the selection. This plant-based diet offers a tremendous number of protective elements in the prevention of many chronic diseases. So this Independence Day and beyond, plan to have on hand some mouth-watering healthy choices.

» A staple of the Mediterranean pantry, beans are a healthy, versatile and super affordable ingredient. Rich in antioxidants, fiber, B vitamins and iron, they are a hearty great alternative to high-fat proteins. Serve guests the following three-bean salad as a side dish at your next summer barbecue or picnic. 

Three-Bean Salad

YIELD: Makes 10 servings

INGREDIENTS:

1 15-ounce can of black beans

1 15-ounce can of red kidney beans

1 15-oounce can of cannellini beans

1 yellow bell pepper, chopped

½ red onion, finely chopped

¼ cup olive oil

2 tablespoons red wine vinegar or to taste

1 clove garlic, minced

1 small bunch cilantro, basil or parsley, chopped

¼ cup dill pickle, diced

¼ cup celery, chopped

Salt and pepper to taste

DIRECTIONS: 

Wash and drain the beans. Transfer to large bowl. Add remaining ingredients, toss well and refrigerate for a few hours before serving.

References:

(1) Nature. 2010;467:1114-1117. (2) Epidemiol Prev Anno 2007;31(Suppl 1). (3) Cancer Causes Control. 2010;21:493-500. (4) Am J Epidemiol. 1994 Jan 1;139(1):1-15. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-1711. (7) Neurology. 2011 Aug 2;77(5):418-425. 

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

Lack of exercise is the dominant risk factor for heart attacks. Stock photo
Over the age of 30, inactivity creates the greatest risk

By David Dunaief, M.D.

Dr. David Dunaief

In last week’s article, I wrote about unusual symptoms that may indicate a myocardial infarction (heart attack) and the importance of knowing these atypical major symptoms beyond chest pain. This is not an easy task. I thought a good follow-up to that article would be one that focused on preventable risk factors.

The good news, as I mentioned previously, is that we have made great strides in reducing mortality from heart attacks. When we compare cardiovascular disease — heart disease and stroke — mortality rates from 1975 to the present, there is a substantial decline of approximately one-quarter. However, if we look at these rates since 1990, the rate of decline has slowed (1).

Plus, one in 10 visits to the emergency room are related to potential heart attack symptoms. Luckily, only 10 to 20 percent of these patients actually are having a heart attack (2). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. The obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. Less obvious risk factors include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, also may help allay the risks.

Let’s look at the evidence.

Obesity

On a board exam in medicine, if smoking is one of the choices with disease risk, you can’t go wrong by choosing it. Well, it appears that the same axiom holds true for obesity. But how substantial a risk factor is obesity? 

In the Copenhagen General Population Study, results showed an increased heart attack risk in obese (BMI >30 kg/m²) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m²) (3). The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Since this was an observational trial, we can only make an association, but if it is true, then there may not be such a thing as a “metabolically healthy” obese patient. Therefore, if you are obese, it is really important to lose weight.

Sedentary lifestyle

If obesity were not enough of a wake-up call, let’s look at another aspect of lifestyle: the impact of being sedentary. An observational study found that activity levels had a surprisingly high impact on heart disease risk (4). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect on women’s heart disease risk. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over the age of 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported and not necessarily measured in a doctor’s office, it may have been underestimated as a risk factor for heart disease. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Gout

When we think of gout, we relate it to kidney stones. But gout increases the risk of heart attacks by 82 percent, according to an observational study (6). Gout tends to affect patients more when they are older, but the risk of heart attack with gout is greater in those who are younger, ages 45 to 69, than in those over 70. What can we do to reduce these risk factors?

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (7).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is the fact that those who increased their fiber after the cardiovascular event had a 31 percent reduction in mortality risk. In this analysis, it seemed that more of the benefit came from fiber found in cereal. The most intriguing part of the study was the dose response. For every 10-g increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events such as heart attacks (8).

Osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? Well, in a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack. (5) Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References:

(1) Heart. 1998;81(4):380. (2) JAMA Intern Med. 2014;174(2):241-249. (3) JAMA Intern Med. 2014;174(1):15-22. (4) Br J Sports Med. 2014, May 8. (5) Presented Research: World Congress on OA, 2014. (6) Rheumatology (Oxford). 2013 Dec;52(12):2251-2259. (7) BMJ. 2014;348:g2659.  (8) N Engl J Med. 2000;343(1):16.

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

Being a couch potato is detrimental to your health. Stock photo
Hint — it’s not only about weight

By David Dunaief, M.D.

Dr. David Dunaief

What causes Type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 12.2 percent of the U.S. population aged 18 or older has Type 2 diabetes, and about 9.4 percent when factoring all ages (1).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars because form is important. Sugar and fruit are not the same with respect to their effects on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of Type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage; however, we are talking about the overall prevalence, which is around 9.4 percent in the U.S., as we noted above.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12-ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. 

Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to municipal efforts to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

The effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — Type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a body mass index of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels. It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have Type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat Type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with articles I’ve written on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

Thus, diabetes is most likely a disease caused by a multitude of factors, including obesity, sedentary lifestyle and visceral fat. The good news is that many of these factors are modifiable. Cinnamon and fruit seem to be two factors that help decrease this risk, as does exercise, of course.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make at least some lifestyle modifications. So America, take an active role.

References:

(1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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. 

TIAs are a serious warning sign of stroke and should not be ignored.
Ministrokes are not inconsequential

By David Dunaief, M.D.

Dr. David Dunaief

A TIA (transient ischemic attack) is sometimes referred to as a ministroke. This is a disservice since it makes a TIA sound like something that should be taken lightly. Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot across the bow that needs to be taken very seriously on its own merit. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (1). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. I have helped manage patients with symptoms as understated as the onset of double vision. Other symptoms may include facial or limb weakness on one side, slurred speech or problems comprehending others, dizziness or difficulty balancing or blindness in one or both eyes (2). TIA incidence increases with age (3).

What is a TIA?

TIAs are a serious warning sign of stroke and should not be ignored.

The definition has changed over time from one purely based on time (less than one hour), to differentiate it from a stroke, to one that is tissue based. It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia (low blood flow in the back of the eye) without evidence of acute infarction (tissue death) (4). In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, creating difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Why take a TIA seriously if its debilitating effects are temporary? 

Though they are temporary, TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death. Despite the seriousness of TIAs, patients or caregivers often delay receiving treatment.

Stroke risk

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (5). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (6). Even worse, over the long term, the probability that a patient will experience a stroke reaches approximately 30 percent, one in three, after five years (7).

To go even further, there was a study that looked at the immediacy of treatment. The EXPRESS study, a population-based study that considered the effect of urgent treatment of TIA and minor stroke on recurrent stroke, evaluated 1,287 patients, comparing their initial treatment times after experiencing a TIA or minor stroke and their subsequent outcomes (8).

The Phase 1 cohort was assessed within a median of three days of symptoms and received a first prescription within 20 days. In Phase 2, median delays for assessment and first prescription were less than one day. All patients were followed for two years after treatment. Phase 2 patients had significantly improved outcomes over the Phase 1 patients. Ninety-day stroke risk was reduced from 10 to 2 percent, an 80 percent improvement.

The study’s authors advocate for the creation of TIA clinics that are equipped to diagnose and treat TIA patients to increase the likelihood of early evaluation and treatment and decrease the likelihood of a stroke within 90 days. The moral of the story is: Treat a TIA as a stroke should be treated, the faster the diagnosis and treatment, the lower the likelihood of sequela, or complications.

Predicting the risk of stroke complications

Both DWI (diffusion weighted imaging) and ABCD2 are potentially valuable predictors of stroke after TIA. The ABCD2 is a clinical tool used by physicians. ABCD2 stands for Age, Blood pressure, Clinical features and Diabetes, and it uses a scoring system from 0 to 7 to predict the risk of a stroke within the first two days of a TIA (9).

Heart attack

In one epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (10). These were patients without known heart disease. Interestingly, the risk of heart attacks was much higher in those over 60 years of age and continued for years after the event. Just because you may not have had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack. Even patients taking statins to lower cholesterol were at higher risk of heart attack after a TIA.

Mortality

If stroke and heart attack were not enough, TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years and by 20 percent after nine years, especially in those over age 65, according to a study published in Stroke (11). The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort (particular group of patients) study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (12). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (13). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include a Mediterranean and DASH diet combination. Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

In researching information for this article, I realized that there are not many separate studies for TIA; they are usually clumped with stroke studies. This underscores the seriousness of this malady. If you or someone you know has TIA symptoms, the patient needs to see a neurologist and a primary care physician and/or a cardiologist immediately for assessment and treatment to reduce risk of stroke and other long-term effects.

References:

(1) Stroke. Apr 2005;36(4):720-723; Neurology. May 13 2003;60(9):1429-1434. (2) mayoclinic.org. (3) Stroke. Apr 2005;36(4):720-723. (4) N Engl J Med. Nov 21 2002;347(21):1713-1716. (5) Neurology. 2011 Sept 27; 77:1222. (6) Lancet Neurol. Dec 2007;6(12):1063-1072. (7) Albers et al., 1999. (8) Stroke. 2008;39:2400-2401. (9) Lancet. 2007;9558;398:283-292. (10) Stroke. 2011; 42:935-940. (11) Stroke. 2012 Jan;43(1):79-85. (12) Stroke. 2011 Jul;42(7):1857-1861. (13) JAMA. 2005 Mar 23;293(12):1435.

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. 

It is very important to take white-coat hypertension seriously. Stock photo
As many as 30 percent of patients experience this phenomenon

By David Dunaief, M.D.

Dr. David Dunaief

White-coat hypertension (high blood pressure) is defined as blood pressure that is elevated to at least 140/90 mm Hg at a physician’s office, but “normal” when measured at home. The blood pressure considered normal at home for most Americans is less than 135/85 mm Hg. This is a real phenomenon caused by the anxiety or stress of being in a doctor’s office. It is also known as “isolated office hypertension.”

About 15 to 30 percent of patients experience white-coat hypertension (1). However, when the diastolic (bottom number) blood pressure is greater than 105 mm Hg, it is unlikely to be simply caused by doctor’s office-related stress (2).

Consequences

What are the consequences of white-coat hypertension? The first challenge is that physicians may overtreat it, prescribing medications that lead to low blood pressure when not in the office. Alternately, we sometimes discount it because it seems benign or harmless. However, some studies show that it may increase the risk of sustained hypertension, which is a major contributor to developing cardiovascular disease — heart disease and stroke.

It is very important to take white-coat hypertension seriously because Centers for Disease Control and Prevention data show that the percentage of adults age 20 and over with hypertension reached 33.5 percent in the 2013-14 period (3).

What can be done?

What can be done about white-coat hypertension? Well, it does not need to be treated with medication, except potentially in elderly patients (over 80 years of age) but should involve lifestyle modifications, including dietary changes, stress reduction and exercise. In terms of diet, increased beet juice, green leafy vegetables and potassium, as well as decreased sodium intake may be important. You should monitor the blood pressure at home, taking multiple readings during the day, or by 24-hour ambulatory blood pressure readings, which require wearing a monitor. The latter provides the additional advantage of blood pressure readings during your sleep.

If you do monitor your blood pressure at home, the American Heart Association has suggestions on how to get the most accurate readings, such as measurements early in the morning before exercising and eating, as well as in the evening (4). You should also be comfortably seated, don’t cross your legs, and sit/relax for a few minutes before taking a reading. Let’s look at the evidence.

Risk of sustained high blood pressure

There were no substantial studies demonstrating any consequences from white-coat hypertension until 2005. Most previous studies on white-coat hypertension were not of long enough duration.

In the 2005 population-based Ohasama study, results showed that the participants who had white-coat hypertension were 2.9 times more likely to develop sustained hypertension, compared to those who had normal blood pressure in the doctor’s office (5). There were almost 800 participants involved in this study, with a mean age at the start of 56. What was really impressive about the study was its duration, with an eight-year follow-up. This gives a better sense of whether white-coat hypertension may develop into sustained hypertension. The researchers concluded that it may lead to a less than stellar outlook for cardiovascular prognosis.

Another study, published in 2009, reinforced these results. The PAMELA study showed that those with white-coat hypertension had about a 2.5-times increased risk of developing sustained high blood pressure, compared to those who had normal readings in all environments (6). There were 1,412 participants involved in the study, ranging in age from 25 to 74. Just like the previous study, an impressive aspect was the fact that there was a long follow-up period of 10 years. Thus, this was a substantial study, applicable to the general population over a significant duration.

Prevention of sustained hypertension

In a small, randomized controlled trial, beet juice was shown to reduce blood pressure significantly (7). Patients either were given 250 ml (about 8 ounces) of beet juice or comparable amounts of water. The patients who drank the beet juice saw an 11.2 mm Hg decrease in blood pressure, while those who drank water saw a 0.7 mm Hg reduction. This effect with the beet juice continued to remain significant. Even after 24 hours, there was a sustainable 7.2 mm Hg drop in blood pressure, compared to readings taken prior to drinking the juice. Although these results are encouraging, we need to study whether these effects can be sustained over the long term. Also, this study was done in patients with high blood pressure. I don’t know of any prevention studies done in patients with white-coat hypertension.

The researchers believe the effect is caused by high nitrate levels in beet juice that are converted to nitrite when it comes in contact with human saliva. Nitrite helps to vasodilate, or enlarge blood vessels, and thus helps to decrease blood pressure in a similar way as some antihypertensive (blood pressure) medications. The authors go on to surmise that green leafy vegetables offer protection from cardiovascular disease in part due to increased nitrite levels, similar to those in beet juice. 

A subsequent double-blind, placebo-controlled clinical trial with 68 hypertensive patients found that blood pressure was significantly reduced in the clinic and in home readings over a four-week period, when compared to nitrate-free beet juice (8).

If you have diabetes, prediabetes, a family history or a high risk for diabetes, I recommend eating beets instead, since drinking beet juice will raise your sugar levels.

Increasing potassium levels significantly through food sources, not supplements, has a profound effect in reducing blood pressure. In a study where 3,500 to 4,700 mg of potassium were consumed through foods, the systolic (top number) blood pressure was reduced by 7.1 mm Hg (9). We should be getting 4,700 mg of potassium daily, which equates to about 10 bananas daily. Almonds, raisins and green leafy vegetables, such as Swiss chard, also have significant amounts of potassium.

White-coat hypertension should not be neglected. It is important to monitor blood pressure at home for at least three days with multiple readings, and then send them to your physician for review. Though patients don’t need to be on blood pressure medications at this stage, it does not mean you should be passive about the process. Make lifestyle modifications to reduce your risk of developing sustained hypertension.

References:

(1) Hypertension. 2013;62:982-987, originally published Nov 13, 2013. (2) J Hypertens. 2001;19(6):1015. (3) cdc.gov. (4) Am Fam Physician. 2005 Oct 1;72(7):1391-1398. (5) Arch Intern Med. 2005 Jul 11;165(13):1541-1546. (6) Hypertension. 2009; 54: 226-232. (7) Hypertension. Online 2013; April 15. (8) Hypertension. 2015 Feb; 65(2): 320–327. (9) BMJ. 2013 Apr 3;346:f1378. 

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.

Accumulating evidence supports an association between depression and inflammation. Stock photo
C-reactive protein is an important biomarker

By David Dunaief, M.D.

Dr. David Dunaief

Many of us have inflammation in our bodies, inflammation that is a potential underlying cause for a great number of diseases. Can we demonstrate the level of inflammation by measuring it? The answer is yes.

One of the most widely studied biomarkers for inflammation is high-sensitivity C-reactive protein (hsCRP), also referred to as CRP. High sensitivity means that we can measure levels as low as 0.3 mg/L more accurately.

What is the significance of the different levels? In heart disease, individuals who have levels lower than 1.0 mg/L are in the optimal range for low risk of inflammation. Levels of 1 to 3 mg/L represent the average risk range, and greater than 3.0 mg/L is a higher risk profile. Above 10.0 mg/L is less specific to heart disease, although still related, but more likely associated with other causes, such as infection and autoimmune diseases (1, 2). This biomarker is derived from the liver.

CRP is not specific to heart disease, nor is it definitive for risk of the disease. However, the upside is that it may be helpful with risk stratification, which helps us understand where we sit on a heart disease risk spectrum and with progression in other diseases, such as age-related macular degeneration, diabetic retinopathy, depression and autoimmune diseases. Let’s look at the evidence.

Age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness in patients over the age of 65 (3). Therefore, it is very important to help define risk stratification for this disease. In a prospective study, results showed that hsCRP levels were inversely associated with the risk of developing AMD. The group with an hsCRP greater than 3.0 mg/L had a 50 percent increased risk of developing overall AMD compared to the optimal group with hsCRP lower than 1.0 mg/L. But even more interestingly, the risk of developing neovascular, or wet, AMD increased to 89 percent in this high-risk group.

The significance of wet AMD is that it is one type of advanced-stage AMD that results in blindness. This study involved five studies where the researchers thawed baseline blood samples from middle-aged participants who had hsCRP levels measured. There were more than 2,000 participants with a follow-up as long as 20 years. According to the study’s authors, annual eye exams and lifestyle modifications, including supplements, may be able to stem this risk by reducing hsCRP.

These results reinforce those of a previous prospective study that showed that elevated hsCRP increased the risk of AMD threefold (4). This study utilized data from the Women’s Health Study, which involved over 27,000 participants. Like the study mentioned above, this one also defrosted blood samples from baseline and looked at follow-up incidence of developing AMD in initially healthy women.

The highest group had hsCRP levels over 5.2 mg/L. Additionally, when analyzing   similar cutoffs for high- and low-level hsCRP, as the above trial used, those with hsCRP over 3.0 had an 82 percent increased risk of AMD compared to those with an hsCRP of lower than 1.0 mg/L.

Diabetic retinopathy — a complication of diabetes

We know that diabetes affects approximately 10 percent of the U.S. population and is continuing to rise at a rapid rate. One of the complications of diabetes affects the retina (back of the eye) and is called diabetic retinopathy. This is a leading cause of vision loss (5). One of the reasons for the vision loss is macular edema, or swelling, usually due to rupture of tiny blood vessels below the macula, a portion of the back of the eye responsible for central vision.

The Diabetes Control and Complications Trial (DCCT), a prospective study involving over 1,400 Type 1 diabetes patients, showed an 83 percent increased risk of developing clinically significant macular edema in the group with the highest hsCRP levels compared to those with the lowest (6). Although these results were with Type 1 diabetes, patients with Type 2 diabetes are at equal risk of diabetic retinopathy if glucose levels, or sugars, are not well controlled.

Depression

Depression is a very difficult disease to control and is a tremendous cause of disability. If we can minimize the risk of complications and hospitalizations, this is probably the most effective approach.

Well, it turns out that inflammation is associated with depression. Specifically, in a prospective observational trial, rising levels of CRP had a linear relationship with increased risk of hospitalization due to psychological distress and depression (7).

In other words, compared to levels of less than 1 mg/L, those who were 1 to 3 mg/L, 3 to 10 mg/L and greater than 10 mg/L had increased risk from 30 to 84 to 127 percent, respectively. This study involved over 70,000 patients.

What can be done to reduce inflammation?

This is the key question, since we now know that hsCRP is associated with systemic inflammation. In the Nurses’ Health Study, a very large, prospective observational study, the Dietary Approaches to Stop Hypertension (DASH) diet decreased the risk of both heart disease and stroke, which is impressive. The DASH diet also decreases the levels of hsCRP significantly, which was associated with a decrease in clinically meaningful end  points of stroke and heart disease (8).

The DASH diet is nutrient dense with an emphasis on fruits, vegetables, nuts, seeds, legumes and whole grains and a de-emphasis on processed foods, red meats, sodium and sweet beverages.

Conclusion

As the evidence shows with multiple diseases, hsCRP is a very valuable nonspecific biomarker for inflammation in the body.

To stem the effects of inflammation, reducing hsCRP through lifestyle modifications and drug therapy may be a productive way of reducing risk, slowing progression and even potentially reversing some disease processes.

The DASH diet is a very powerful approach to achieving optimal levels of hsCRP without incurring potential side effects. This is a call to arms to have your levels measured, especially if you are at high risk or have chronic diseases such as heart disease, diabetes, depression and autoimmune diseases. HsCRP is a simple blood test with easy-to-obtain results.

References:

(1) uptodate.com. (2) Diabetes Technol Ther. 2006;8(1):28-36. (3) Prog Retin Eye Res. 2007 Nov;26(6):649-673. (4) Arch Ophthalmol. 2007;125(3):300-305. (5) Am J Ophthalmol. 2003;136(1):122-135. (6) JAMA Ophthalmol. 2013 Feb 7;131:1-8. (7) JAMA Psychiatry. 2013;70(2):176-184. (8) Arch Intern Med. 2008;168(7):713-720.

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.

It was five years since I had a colonoscopy, so I made an appointment to repeat the procedure. It was not a date on the calendar I was looking forward to. I understand the importance of this test for me, so I did what I had to do. My dad died of intestinal cancer, as did several of his siblings, so the family warning is clear. Had this test been available at the time he was stricken, and his cancer discovered, I have little doubt that my dad, a robust and athletic man, would have otherwise lived a longer life than his 70 years.

A 2015 German study published in the European Journal of Cancer confirmed that colonoscopy screening “will lead to substantial reductions in the colorectal cancer burden.”

So what is a colonoscopy? I write to explain the test in the hopes of encouraging any readers who might be postponing and avoiding that appointment to take care of that little task once they turn 50. It is my understanding that in most cases, health insurance will cover the costs, which in itself is evidence of the importance of the test. And the experience is not so awful. In fact there is, so to speak, a silver lining, but more about that later.

Here are the details. A flexible tube, called a colonoscope, with a video camera on the end that is connected to a large screen in the room, is inserted through the rectum and allows the gastroenterologist to examine the inside of the large intestine. The physician then searches for any abnormalities such as polyps, which can turn into cancer, and usually removes them. The scope rides on a cushion of air that is provided, kind of like a maglev train moves along smoothly without touching the ground through magnetic levitation. The actual procedure takes only about 30-45 minutes, but between the prep at the office and the recovery, it’s a two-to-four hour event.

The first time I had this test, I wanted to be awake to see the inside of the intestine, which is actually quite beautiful. It looks like a braid, as much more surface area can effectively fit into a small area. Tiny red and blue blood vessels crisscross the sides. Of course in order to see all this clearly, the intestine must first be totally cleaned out, which is probably the less pleasant part of the whole deal. Some fasting is involved, anything red, like a tomato, or a seed or nut that might block the view, is to be avoided, and in the last 12 hours before the test, a liquid laxative that spikes 64 ounces of Gatorade is ingested.

I was advised to wear loose and comfortable clothing and to leave cash and jewelry at home. Upon arrival, I was given two of those infamous hospital gowns, one to face front and the other the rear. My clothes were secured in a locker, and after a thorough history was unhurriedly taken, the nurse placed an intravenous (IV) line into my arm.

After my first experience, I chose to be fully sedated this time. I was given the good news, that all was well, when I awoke. As a result of the sedation, however, I could not just get up and drive but needed to be accompanied by a companion. In my case it was my son, who could steer me through the hallway and into the car, then drive me home. Shortly after I arrived back in the kitchen, I realized I was ravenous and began refilling my intestine.

There is a mild bit of bloating after the test as a result of the air that is added, but that is not particularly uncomfortable and disappears within hours. I was advised not to drive a car, operate any machinery or power tools (unlikely), drink any alcoholic beverages or make any important decisions until the following day.

There are other forms of the colonoscopy that are somewhat less invasive, but my understanding is that this variant is the most thorough and therefore the most desirable. As for the silver lining? I did appear to lose a couple of pounds, at least for now.

Personal Fitness in Rocky Point. Photo from Facebook

By Kevin Redding

A Rocky Point fitness club owner is determined to get people in shape — inside the gym and beyond it.

Since 1989, North Shore residents have been going to Personal Fitness on Route 25A not just to run on the treadmill and get fit for beach season. They go to have their lives transformed by Ed Darcey, the gym’s owner, trainer and “overall cheerleader and therapist,” according to gym members, who are made up of athletes, parents, children, developmentally disabled residents, people in wheelchairs and those struggling with drugs, alcohol or abuse.

Ed Darcey, owner of Personal Fitness in Rocky Point, training a client. Photo from Facebook

“Ed is an inspirational, motivational, kind, empowering and passionate trainer,” said Faith Powers-Raynis, who joined the gym after suffering a spinal cord disease that paralyzed her from the waist down. “Ed is helping me to rebuild the muscles that I lost … I know with Ed’s help, I just might get back on my feet.”

“He’s a wonderful soul,” Lisa Monaco said. “He makes you feel comfortable and pushes you as far as you can go.”

Rob Geneva, a longtime customer turned staff member, said Darcey makes the atmosphere feel less like you’re in a gym and more like the bar from “Cheers.”

“Anybody is welcome and you just get that feeling right when you come in,” he said. “You’re not intimidated.”

Darcey, 54, a Shoreham native and Riverhead High School graduate, said he has always felt a need to help and protect those around him, whether it was a kid at school being bullied or a homeless person on the street asking for money. It’s a feeling that remains.

“If someone needs a hand, I’m going to try and reach out and do my best to help, especially those whose lives maybe aren’t what they should be,” Darcey said. “A lot of our members here see the gym as an outlet, like a second home. Sometimes they’re more comfortable here than they are at their actual home. They come here, get in shape and we all root each other on. I’m trying to help give them a better life if I can.”

A football player throughout high school, Darcey pursued a degree in physical education and health at C.W. Post, where he received his gym certification after three years. In his late 20s, he decided to take advantage of some empty space next door to his parent’s long-running carpet business on Route 25A, and he’s been there ever since.

“From the beginning, I tried to make it very personal and hands-on,” he said. “Lots of other gyms are these big franchises. This is a family-type atmosphere. We have members that have wheelchairs and walkers, and kids with cerebral palsy and Down syndrome. But in my gym, everybody’s the same. Some may have different limitations and abilities, but they’re all the same to me.”

The first time Rocky Point resident Rich Grundmann went to the gym, he saw a young woman with Down syndrome running on a treadmill and mentioned to a nearby trainer that his 12-year-old son Alex had cerebral palsy, wondering if he’d be able to get involved with the gym. The trainer encouraged the father to bring him by.

“After just one session there, my son just lit up,” Grundmann said. “And the personal attention they gave him was incredible. He’s been through all sorts of therapy, personal and occupational, but the trainers here really pushed him and he loves it. It’s amazing the amount of strength he’s built up since going there.”

Alex, he said, moves around in a walker and sometimes a wheelchair, and has a lot of spasticity. The trainers work on stretching his legs and arms to gain more mobility.

Ed Darcey, owner of Personal Fitness in Rocky Point. Photo from Facebook

“It gets frustrating for him at school because he looks around and he wants to do all the sports the other kids do and wants to feel like a regular teenager,” his father said. “But whenever he leaves the gym, he’s on cloud nine. There’s something about that place and Ed where everyone fits in. It’s like a big family.”

Amy Dias of Middle Island, who sustained a traumatic brain injury after a car accident on Middle Country Road in 2003, said Personal Fitness helped her feel confident again. Following the accident, which left her in a coma for nine months, doctors told Dias she would never speak or move again. A year after she joined the gym, she was walking with a cane and talking. She even lives on her own now.

“I’m not afraid to talk to people now and they definitely strengthened my right side, which got affected most,” Dias said. “I love everyone at the gym. Ed is wonderful and really helped me.”

And how did he do the impossible?

“He cares,” she said. “He honestly cares about every individual person.”

The gym owner also helps out in the local community, frequently lending a charitable hand to Ridge Full Gospel Christian Church, where he recently helped to feed and clothe the homeless on Thanksgiving. He raises funds and promotes any and all shelters and charity drives in the area, and is a regular contributor to Betty’s Closet, a store inside the Rocky Point Middle School cafeteria that helps raise money and collect toys and food for families in need.

“Whenever I post something about an upcoming event on my page, he’s always ready to help,” said Betty Loughran, the Rocky Point PTA member who created Betty’s Closet. “He gets all the gym members involved, donates gift cards and goods and whatever the community needs. He’s just a really good person. The gym is always open and if kids in the community are ever in trouble and need a place to go, he’s there for them.”

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