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By David Dunaief, M.D.

Dr. David Dunaief

Obesity is an ongoing struggle for many in the United States. If you, like many, are struggling to shed those extra “COVID-era pounds,” I’m sure you can relate.

Obesity is defined as a BMI (body mass index) of >30 kg/m2. More importantly, obesity can also be defined by excess body fat, which is more important than BMI.

While the medical community has known for some time that excess body fat contributes to poor health outcomes, it became especially visible during the first few rounds of COVID-19.

In the U.S., poor COVID-19 outcomes have been associated with obesity. In a study involving 5700 COVID-19 patients hospitalized in the New York City area, 41.7 percent were obese. The most common comorbidities contributing to hospitalization were obesity, high blood pressure and diabetes (1). In other words, obesity contributed to more severe symptoms.

In a study in China, results showed that those who were overweight were 86 percent more likely to have severe COVID-19 pneumonia, and that percentage increases to 142 percent when patients qualify as obese (2).

And though age is a risk factor for COVID-19, among those younger than 60 and obese, there is a two-times increased risk of being admitted to the hospital, according to a 3,615-patient study at NYU Langone Health (3).

While these studies were on early variants of COVID, the attention and wide-ranging research provide us with an interesting series of studies in how excess weight might impact progression of other acute respiratory diseases.

Why is the risk for severe COVID-19 higher with obesity? 

According to the prevailing theory, obesity may interfere with mechanical aspects of breathing, thus increasing airway resistance and making gas in exchange more difficult in the lung. It may also impede lung volume by exerting pressure on the lungs and may involve weaker muscles necessary for respiration (4).

Why does excess fat affect health outcomes? 

First, some who have elevated BMI may not have a significant amount of fat; they may have more innate muscle, instead. These people are not necessarily athletes. It’s just how they were genetically put together.

More than 25 percent of my patient population is “solidly built,” which means they have greater muscle mass, but also too much excess fat. Visceral fat, which is wrapped around the organs, including the lungs, is the most important.

Fat cells have adipokines, specific cell communicators that “talk” with other fat cells but also other systems such as the brain, immune system, muscles, and liver. Adipokines can be mediators of both inflammation and insulin resistance (5). It’s the inflammation among obese patients that could be the exacerbating factor for hospitalizations and severe illness, according to the author of a 4000-patient COVID-19 study (6). 

How can you reduce inflammation and lose excess fat?

In a randomized controlled trial with 75 participants comparing a plant-based diet to a control diet, there was a greater than 14 lbs. weight reduction and roughly 10 lbs. fat reduction over a 14-week period (7). Of the weight lost, about 70 percent was excess fat. Remember, excess body fat, through adipokines, may be inflammatory and increase the risk of severe disease. 

Weight reduction with a plant-based approach may be results of dietary fiber increases and dietary fat reductions with plant-based diets, according to Physician’s Committee for Responsible Medicine (PCRM) (8). You also want a diet that has been shown to reduce inflammation.

We published a study involving 16 patients from my clinical practice in 2020. It shows that those who ate a whole food plant-based LIFE (low inflammatory foods everyday) diet over a seven-day period had a significant decrease in inflammation measured by hsCRP (high sensitivity c-reactive protein). This occurred in those who completely changed their diets to the LIFE diet, but also occurred in those who simply added a daily greens-and-fruit-based smoothie to their existing diet (9).

In my practice, I have seen many patients lose substantial amounts of weight over a short period. More importantly, they also lost body fat. For instance, a 70-year-old male lost 19 lbs. of weight and 12 lbs. of body fat over a six-week period. His inflammation, which was very high to start, dropped substantially to the border of optimal levels. This patient and many others have seen tandem reductions in both weight and inflammation. To boot, this was a cardiac patient whose cardiologist had considered a stent, but later said he did not need it after reducing his inflammation.

The most recent health crisis shone a spotlight on the importance of losing excess fat. It’s not just about COVID-19 or other respiratory disease severity, although those are concerning. It’s also about excess fat’s significant known contributions to many other chronic diseases, like cardiovascular disease, high blood pressure, and high cholesterol.

References:

(1) JAMA. online April 22, 2020. (2) Clin Med (Lond). 2020 Jul; 20(4): e109–e113. (3) Clin Infect Dis. 2020 Jul 28;71(15):896-897. (4) Chron. Respir. Dis. 5, 233–242 (2008). (5) Front Endocrinol (Lausanne). 2013; 4:71. (6) MedRxiv.com. (7) Nutr Diabetes. 2018; 8: 58. (8) Inter Journal of Disease Reversal and Prevention 2019;1:1. (9) Amer J Lifestyle Med. 2022;16(6):753-764.

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

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Diet may have a significant impact on heart failure risk and outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Unlike a heart attack, which is acute, heart failure develops slowly and may take years to become symptomatic. Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. According to the American Heart Association, over six million Americans are affected, and the numbers are projected to increase significantly by 2030 (1).

There are two types of heart failure, systolic and diastolic. The basic difference is that the ejection fraction, the output of blood with each contraction of the left ventricle of the heart, is more or less preserved in diastolic HF, while it can be significantly reduced in systolic HF.

Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue. Each of these can impact quality of life significantly.

Major lifestyle risk factors for heart failure include obesity; smoking; poor diet, including consuming too much sodium; being sedentary; and drinking alcohol excessively. Conditions that increase your risk include diabetes, coronary artery disease and high blood pressure.

Typically, heart failure is treated with blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. We are going to look at how diet and iron levels can affect heart failure outcomes.

Can diet improve heart failure?

If we look beyond the usual risk factors mentioned above, oxidative stress may play an important role as a contributor to HF.

In a population-based, prospective study, the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (2). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

What makes this study so impressive is that it is the first of its kind to investigate antioxidants from the diet and their impacts on heart failure prevention.

This was a large study, involving 33,713 women, with good duration — follow-up was 11.3 years. There are limitations to this study, because it is observational, and the population involved only women. Still, the results are very exciting, and it is unlikely there is a downside to applying this approach to the population at large.

More recently, the REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. 

The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (3). Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF.

Does iron supplementation improve heart failure outcomes?

An observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (4).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L.

The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients. However, studies of oral iron supplementation has not been shown to improve results, while intravenous supplementation has been shown to reduce hospitalizations and mortality (5).

These studies suggest that we should try to prevent heart failure through dietary changes, including high levels of antioxidants, because it is not easy to reverse the disease. Those with HF should have their ferritin and iron levels checked, because these can be addressed with medical supervision.

References:

(1) Circulation. 2020;141:e139–e596. (2) Am J Med. 2013 Jun:126(6):494-500. (3) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045. (4) Am Heart J. 2013;165(4):575-582. (5) Eur J Heart Fail. 2018;20(1):125–133.

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

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Flu, RSV and COVID-19 are especially tough on those with impaired lung function

By David Dunaief, M.D.

Dr. David Dunaief

Our experiences over the past several years with COVID-19 have increased our awareness of how chronic ailments can make us more vulnerable to the consequences of acute diseases circulating in our communities.

For those with chronic obstructive lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma, as well as those who smoke and vape, the consequences of the flu, RSV and COVID-19 are especially severe.

The good news is that we can do a lot to improve our lung function by exercising, eating a plant-based diet with a focus on fruits and vegetables, expanding lung capacity with an incentive spirometer, and quitting smoking and vaping, which damage the lungs (1). Studies suggest that everyone will benefit from these simple techniques, not only people with compromised lungs.

Do antioxidants improve asthma?

In a randomized controlled trial, results show that, after 14 days, asthma patients who ate a high-antioxidant diet had greater lung function than those who ate a low-antioxidant diet (2). They also had lower inflammation at 14 weeks. Inflammation was measured using a c-reactive protein (CRP) biomarker. Participants in the low-antioxidant group were over two-times more likely to have an asthma exacerbation.

The good news is that there was only a small difference in behavior between the high- and low-antioxidant groups. The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Using carotenoid supplementation in place of antioxidant foods did not affect inflammation. The authors concluded that an increase in carotenoids from diet has a clinically significant impact on asthma in a very short period.

Can increasing fiber lower COPD risk?

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers.

In one study of men, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (3). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain, essentially a whole foods plant-based diet. The “high-fiber” group was still below the American Dietetic Association’s recommended intake of 14 grams per 1,000 calories each day.

In another study, this time with women, participants who consumed at least 2.5 serving of fruit per day, compared to those who consumed less than 0.8 servings per day, experienced a highly significant 37 percent decreased risk of COPD (4).

The highlighted fruits shown to reduce COPD risk in both men and women included apples, bananas, and pears.

What devices can help improve lung function?

An incentive spirometer is a device that helps expand the lungs when you inhale through a tube and cause a ball (or multiple balls) to rise in a tube. This inhalation opens the alveoli and may help you breathe better.

Incentive spirometry has been used for patients with pneumonia, those who have had chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (5). A small study showed that those who trained with an incentive spirometer for two weeks increased their lung function and respiratory motion. Participants were 10 non-smoking healthy adults who were instructed to take five sets of five deep breaths twice a day, totaling 50 deep breaths per day. Incentive spirometers are inexpensive and easily accessible.

In another small, two-month study of 27 patients with COPD, the incentive spirometer improved blood gasses, such as partial pressure carbon dioxide and oxygen, in COPD patients with exacerbation (6). The authors concluded that it may improve quality of life for COPD patients.  

How does exercise help improve lung function?

Exercise can have a direct impact on lung function. In a study involving healthy women aged 65 years and older, results showed that 20 minutes of high-intensity exercise three times a day improved FEV1 and FVC, both indicators of lung function, in just 12 weeks (7). Participants began with a 15-minute warm-up, then 20 minutes of high-intensity exercise on a treadmill, followed by 15 minutes of cool-down with stretching.

Note that you don’t need special equipment to do aerobic exercise. You can walk up steps or steep hills in your neighborhood, do jumping jacks, or even dance around your living room. Whatever you choose, you want to increase your heart rate and expand your lungs. If this is new for you, consult a physician and start slowly. You’ll find that your stamina improves quickly when you do it consistently.

We all should be working to strengthen our lungs. This three-pronged approach of lifestyle modifications — diet, exercise and incentive spirometer — can help.

References:

(1) Public Health Rep. 2011 Mar-Apr; 126(2): 158-159. (2) Am J Clin Nutr. 2012 Sep;96(3):534-43. (3) Epidemiology Mar 2018;29(2):254-260. (4) Int J Epidemiol Dec 1 2018;47(6);1897-1909. (5) Ann Rehabil Med. Jun 2015;39(3):360-365. (6) Respirology. Jun 2005;10(3):349-53. (7) J Phys Ther Sci. Aug 2017;29(8):1454-1457.

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

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Studies suggest lifestyle approaches to improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

Irritable bowel syndrome (IBS) symptoms, such as abdominal pain, cramping, bloating, constipation and diarrhea, can directly affect your quality of life. If you are among the estimated 10 to 15 percent of the population that suffers from IBS symptoms, managing these symptoms can become all-consuming (1).

While diagnosing IBS is challenging, physicians use discrete criteria physicians to provide a diagnosis and eliminate more serious possibilities. The Rome IV criteria comprise an international effort to help diagnose and treat functional gastrointestinal disorders. Using these criteria, which include frequency of pain and discomfort over the past three months, alongside a physical exam helps provide a diagnosis.

Fortunately, there are several approaches to improving symptoms that require only modest lifestyle changes.

How is IBS affected by mental state?

The “brain-gut” connection refers to the direct connection between mental state, such as nervousness or anxiety, to gastrointestinal issues, and vice versa.

Mindfulness-based stress reduction was used in a small, but randomized, eight-week clinical trial with IBS (2). Those in the mindfulness group (treatment group) showed statistically significant results in decreased severity of symptoms compared to the control group, both immediately after training and three months post-therapy.

Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.

Could gluten be a factor in IBS?

Gluten sensitivity may be an important factor for some IBS patients (3). In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo, 68 percent vs. 40 percent, respectively (4). These results were highly statistically significant, and the authors concluded that nonceliac gluten intolerance may exist. 

I suggest to my patients that they might want to start avoiding gluten and then add it back into their diets slowly to see the results.

Does fructose play a role in IBS?

Some IBS patients may suffer from fructose intolerance. In a study, IBS researchers used a breath test to examine this possibility (5). The results were dose-dependent, meaning the higher the dose of fructose, the greater the effect researchers saw. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.

The symptoms of fructose intolerance included gas, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that avoidance of fructose may reduce symptoms in some IBS patients.

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (6). Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.

Are lactose intolerance and IBS connected?

Another small study found that about one-quarter of patients with IBS also have lactose intolerance (7). 

Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptoms at both six weeks and five years when placed on a lactose-restricted diet.

Though the trial was small, the results were statistically significant, which is impressive. Both the patient compliance and long-term effects were excellent, and visits to outpatient clinics were reduced by 75 percent. This demonstrates that it is probably worthwhile to test patients who have IBS symptoms for lactose intolerance.

Will probiotics help with IBS?

A study that analyzed 42 trials focused on treatment with probiotics shows there may be a benefit to probiotics, although the objectives, or endpoints, were different in each trial (8).

Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.

Is there a link between IBS and migraines?

A preliminary study has suggested there may be a link between IBS and migraine and tension-type headaches. The study of 320 participants, 107 with migraine, 107 with IBS, 53 with episodic tension-type headaches (ETTH), and 53 healthy individuals, identified significant occurrence crossover among those with migraine, IBS and ETTH. Researchers also found that these three groups had at least one gene that was distinct from healthy participants. Their hope is that this information will lead to more robust studies that could result in new treatment options (9).

All of these studies provide hope for IBS patients. These are treatment options that involve modest lifestyle changes. Since the causes can vary, a strong patient-doctor connection can help in selecting an approach that provides the greatest symptom reduction for each patient.

References:

(1) American College of Gastroenterology [GI.org]. (2) Am J Gastroenterol. 2011 Sep;106(9):1678-1688. (3) Am J Gastroenterol. 2011 Mar;106(3):516-518. (4) Am J Gastroenterol. 2011 Mar;106(3):508-514. (5) Am J Gastroenterol. 2003 June;98(6):1348-1353. (6) J Clin Gastroenterol. 2008 Mar;42(3):233-238. (7) Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944. (8) Aliment Pharmacol Ther. 2012 Feb;35(4):403-413. (9) American Academy of Neurology 2016, Abstract 3367.

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

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Lowering your sodium intake can help

By David Dunaief, M.D.

Dr. David Dunaief

Although it’s possible to have a kidney stone without symptoms, more often they present with the classic symptoms of blood in the urine and colicky pain. The pain can be intermittent or constant, and it can range from dull to extremely painful, described by some as being worse than giving birth, being shot or being burned. The pain can radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1).

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

Unfortunately, the first line treatment for passing kidney stones — at least small ones — involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are smaller than four millimeters pass spontaneously. Stones closest to the opening of the urethra are more likely to pass through on their own (2).

Generally, if you’ve passed a kidney stone, you know it.

In the case of a stone too large to pass naturally, a urologist may use surgery, ultrasound, or a combination of methods to break it into smaller pieces, so you can pass it. Unfortunately, once a patient forms one stone, the possibility of having others increases significantly over time. The good news is that there are several lifestyle changes you can make to reduce your risk.

How much water do you need to drink?

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

Do supplements play a role in stone formation?

One of the simplest methods is to reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones. Calcium oxalate is the dominant one, occurring approximately 80 percent of the time (4). Calcium supplements, therefore, increase the risk of kidney stones.

When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (5). According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (6). It did not matter whether study participants were taking calcium citrate or calcium carbonate supplements.

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

What role does sodium play in stone formation?

Again, in the Nurses’ Health Study, participants who consumed 4.5 grams of sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 grams per day (6). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Does protein play a role in stone formation?

Animal protein may play a role. In a five-year, randomized clinical trial, men who reduced their consumption of animal protein to approximately two ounces per day, as well as lowering their sodium, were 51 percent less likely to experience a kidney stone than those who consumed a low-calcium diet (7). These were men who had histories of stone formation.

The reason animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that animal protein’s higher sulfur content produces more acid. This acid is neutralized by release of calcium from the bone (8). That calcium can then promote kidney stones.

Does blood pressure impact kidney stones?

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (9). Amazingly, it did not matter whether or not the patients were treated for high blood pressure with medications; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not just the symptoms. The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more that you implement, the lower your likelihood of stones.

References:

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

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

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Dr. Neal Murphy. Photo courtesy of NYCBS

New York Cancer & Blood Specialists (NYCBS) recently announced the addition of oncologist-hematologist Neal Murphy, MD. 

Dr. Murphy will practice at 750 Old Country Rd, Riverhead,640 County Rd, Southampton, and 49 Route 347, Port Jefferson Station.

“Dr. Murphy’s dedication to research and patient care is truly commendable,” said Jeff Vacirca, MD, CEO of NYCBS. “We are proud to have Dr. Murphy join our practice and look forward to the positive impact he will make in the lives of our patients.”

Dr. Murphy has dedicated his time to research focusing on kidney and bladder cancer. Dr. Murphy completed two translational research studies, including “Prognostic molecular signatures for metastatic potential in clinically low-risk stage I and II clear cell renal cell carcinomas,” which was published in Frontiers in Oncology, and “Predictive molecular biomarkers for determining neoadjuvant chemosensitivity in muscle-invasive bladder cancer” which was published in Oncotarget. 

Dr. Murphy has several other peer-reviewed publications and has presented his work at national conferences. He remains passionate about optimizing treatments in hematology/oncology and treats a broad spectrum of diseases with a focus on genitourinary, lung, head and neck, colorectal and skin malignancies, as well as multiple myeloma and lymphoma.

“I strive to get to know all my patients, build trust and provide the kind of care that one of my family members or I would want to receive,” Dr. Murphy said. 

“When communicating with patients, I am honest and open, explaining all treatment options and agreeing on the best, personalized treatment plan together. It is rewarding to be able to alleviate a patient’s anxiety and fear about their diagnosis and to be able to provide hope because there are so many effective treatments NYCBS and I can offer to help patients.”

To make an appointment with Dr. Murphy, please call 631-751-3000. For more information, visit nycancer.com.

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Stony Brook Medicine’s new facility at Smith Haven Mall. Photo by Aidan Johnson
By Aidan Johnson

When a person plans a trip to the mall, they may imagine buying new clothes, browsing storefronts and eating at the food court. Now they can add a trip to the doctor’s office to their list.

Stony Brook Medicine has opened a new advanced specialty care facility at the Smith Haven Mall in Lake Grove. The approximately 170,000-square-foot space, previously occupied by Sears, is now host to a plethora of specialties, offering a “one-stop shop” to patients.

Sharon Meinster, the assistant vice president of facilities planning and design, and Dr. Todd Griffin, vice president for clinical services and vice dean for clinical affairs at Stony Brook Medicine, explained how the new facility would be more accessible for patients than the offices at Technology Drive in Setauket.

The facility will open in multiple phases, likely to be completed by 2027. As their leases end at Technology Drive, the other practices will gradually make their way to Lake Grove. 

“What’s great here is that there’s much better public transportation to the mall,” Griffin said. “That was one of the things that we used to hate about tech parks because many of our patients were taking two or three buses to get there.”

The closest bus stop to Technology Drive is at Belle Meade Road, and if the practice was located farther down the park, it could be difficult for a patient to get there, especially in inclement weather such as heat waves or snowstorms.

There will also be an urgent care complex built in the automotive center at the Smith Haven Mall, which will have direct ambulance support to Stony Brook University Hospital.

Since the new location connects to the rest of the mall, the idea of a buzzer system, similar to those found in restaurants, was considered, allowing patients to walk around the mall while they wait, though Griffin does hope to cut down the wait times.

The phase one services, which are currently open and occupy 60,000 out of the 170,000 square feet, include family and preventive medicine, primary and specialty care, pediatrics, diabetes education, genetic counseling, neurology, neuropsychology and pain management.

The facility will help to foster collaboration between the different doctors since they will all be under one roof.

“It’s nice to have sort of the neuro institute people together,” Griffin said, adding, “You have the surgeons and the docs all in the same space, which helps with collaboration.”

“Right now, they’re in two different locations. So when they move here, they’ll be all together,” he added, “and it’s the same thing with our comprehensive pain center.”

Stony Brook Medicine will also continue to build its Commack location, which has been open since 2017. That building sits at around 350,000 square feet and houses around 38 specialties. They aim to open a surgical center as well as an advanced urgent care center by early 2025.

Despite not having many windows, the Lake Grove facility’s lighting and paint job help to create a more welcoming atmosphere. With much more to come from the Stony Brook care facility, it is already offering a fast and easy way for locals to see their doctor and then grab a pretzel on the way out.

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Proton pump inhibitors should be taken at the lowest dose for the shortest possible time.

By David Dunaief, M.D.

Dr. David Dunaief

Sometimes referred to as “reflux” or “heartburn,” Gastroesophageal reflux disease (GERD) is one of the most treated diseases in the U.S. Technically, heartburn is a symptom of GERD, so this is a bit of a misnomer.

Proton pump inhibitors (PPIs), first launched in 1989, have become one of the top-10 drug classes prescribed or taken over-the-counter (OTC). PPIs currently available OTC include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), and Aciphex (rabeprazole). These and others are also available by prescription.

Their appeal among physicians has been their possible role in the reduction of esophageal cancer resulting from Barrett’s Esophagus. Interestingly, recent studies note that this perceived benefit may not be real (1).

PPIs are not intended for long-term use, because of their robust side effect profile. The FDA currently suggests that OTC PPIs should be taken for no more than a 14-day treatment once every four months. Prescription PPIs should be taken for 4 to 8 weeks (2).

However, their OTC availability can lead patients to take them too long or too often to manage reflux rebound effects when PPIs are discontinued without physician oversight. In addition, some existing medical risks are heightened by PPIs. 

Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures, increased cardiac and vascular risks, vitamin malabsorption issues and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

PPIs and the kidneys

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (3). All of the patients started study with normal kidney function, based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a 17 percent increased risk.

The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (4).

Increased dementia risk

A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (5). These patients were at least age 75. The authors surmise that PPIs may cross the blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk. Researchers also did not take into account high blood pressure, excessive alcohol use or family history of dementia, all of which influence dementia occurrence.

Increased fracture risk

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (6). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (7).

Vitamin absorption issues

In addition to calcium absorption issues, PPIs may have lower absorption effects on magnesium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (8). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

A second study, a meta-analysis of nine studies, confirmed these results: PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (9). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

Another study’s results showed long-term use of over two years increased vitamin B12 deficiency risk by 65 percent (10).

The bottom line

It’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as an H2 blocker (Zantac, Pepcid). In addition, PPIs may interfere with other drugs you are taking, such as Plavix (clopidogrel).

Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (11).

If you do need medication, recognize that PPIs don’t give immediate relief and should only be taken for a short duration to minimize their side effects.

References:

(1) PLoS One. 2017; 12(1): e0169691. (2) fda.gov. (3) JAMA Intern Med. 2016;176(2). (4) JAMA Intern Med. 2016;176(2):172-174. (5) JAMA Neurol. online Feb 15, 2016. (6) Osteoporos Int. online Oct 13, 2015. (7) Am J Med. 118:778-781. (8) PLoS Med. 2014;11(9):e1001736. (9) Ren Fail. 2015;37(7):1237-1241. (10) Mayo Clinic Proceedings. 2018 Feb;93(2):240-246. (11) Am J Gastroenterol 2015; 110:393–400.

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

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Sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques linked to Alzheimer's disease. METRO photo
A few extra ZZZs can help clear brain clutter

By David Dunaief, M.D.

Dr. David Dunaief

Cognitive loss, or mental decline, is a common concern as we age. So much so that a cottage industry of app-based games has sprouted to help keep our brains sharp.

What do we know about the brain, really, though? Startlingly little. We do know that certain drugs, head injuries and lifestyle choices have negative effects, along with numerous neurological, infectious, and rheumatologic disorders and diseases.

Some, like dementia, Parkinson’s, and strokes, are recognized for some of their effects on the brain. However, others – lupus, rheumatoid arthritis, psychiatric mood disorders, diabetes and heart disease – also can have long-term effects on our brains.

These disorders generally have three signs and symptoms in common: they cause either altered mental status, physical weakness, or mood changes — or a combination of these.

Of course, addressing the underlying medical disorder is critical. Fortunately, several studies also suggest that we may be able to help our brains function more efficiently and effectively with rather simple lifestyle changes: sleep, exercise and possibly omega-3s.

How does brain clutter affect us?

Are 20-somethings sharper and more quick-witted than those over 60?

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

This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something.

What if we could reboot our brains, just like we do a computer or smartphone? This may be possible through sleep, exercise and omega-3s.

Why does sleep help?

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

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

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

In an Australian study, results showed that sleep deprivation may have contributed to an almost one percent decline in gross domestic product (3). Why? When people don’t get enough sleep, they are not as productive. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness on short-term basis, we can’t do this continually.

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

How does exercise help your brain?

One study with rats suggests that a lack of exercise can cause unwanted new brain connections. Rats that were not allowed to exercise were found to have rewired neurons around their medulla, the part of the brain involved in breathing and other involuntary activities. This included more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (6). 

Among the rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart. We need human studies to confirm this impact.

Omega-3 fatty acids may affect brain volume

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

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

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

References:

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

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

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Vitamin D supplement
Obesity can reduce the benefits of supplementation

By David Dunaief, M.D.

Dr. David Dunaief

Here in the Northeast, it’s the time of year when colder temperatures mean we’re spending lots of time indoors. When we are outside, we cover most of our skin to protect us from the cold. This means we’re not getting a lot of sun. While this will make your dermatologist happy, it also means you’re probably not converting that sun exposure to vitamin D3.

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

Many of us receive food-sourced vitamin D from fortified packaged foods, where vitamin D has been added. This is because sun exposure — even under the best of circumstances — will not address all of our vitamin D needs. For example, in a study of Hawaiians, a subset of the study population who had more than 20 hours of sun exposure without sunscreen per week, some participants still had low vitamin D3 values (1).

We know vitamin D’s importance for bone health, but we have mixed data for other diseases, such as cardiovascular, autoimmune and skin diseases and cancer.

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

Are there cardiovascular benefits to vitamin D?

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. The Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (3).

However, a small randomized controlled trial (RCT) called the cardioprotective effects of vitamin D into question (4). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2,500 IUs. Some of the weaknesses of the study were a very short duration and small study size.

How does vitamin D affect mortality?

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

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

Does obesity affect vitamin D absorption?

A recently published analysis of data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, found that those with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (2). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs showed none of these benefits.

Can vitamin D help you lose weight?

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (6).

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

USPSTF recommendations and fracture risk

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (7). The supplement combination does not seem to reduce fractures, but does increase the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

When should you supplement?

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

References:

(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) JAMA Netw Open. 2023 Published online Jan 2023. (3) Circulation. 2008 Jan 29;117(4):503-511. (4) PLoS One. 2012;7(5):e36617. (5) J Women’s Health (Larchmt). 2012 Jun 25. (6) J Clin Endocrinol Metabol. May 17, 2012 online. (7) JAMA. 2018;319(15):1592-1599.

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

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