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lifestyle changes

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

This can have a dramatic impact on quality of life.

Treating elevated blood pressure

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

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

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

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

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

Treating Stage 1 hypertension

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

References: 

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

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

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Studies show that running just 5 to 10 minutes each day may help reduce your risk of death from heart attacks, strokes, and other common diseases. Pixabay photo
Add quality years with modest lifestyle changes

By David Dunaief, M.D.

Dr. David Dunaief

The number of 90-year-olds is growing in the U.S. According to the National Institutes of Health, those who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those aged 85 and older.

What do these people have in common? According to one study, they tend to have fewer chronic morbidities or diseases. Thus, they tend to have a better quality of life with greater physical functioning and mental acuity (2).

In a study of centenarians, genetics played a significant role. Characteristics of this group were that they tended to be healthy and then die rapidly, without prolonged suffering (3). In other words, they grew old “gracefully,” staying mobile and mentally alert.

Factors that predict one’s ability to reach this exclusive club may involve both genetics and life-style choices. Let’s look at the research.

Get modest exercise

We are told repeatedly to exercise. Here’s one reason. Results of one study showed that 5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular and all-cause mortality (4).

Amazingly, even if participants ran fewer than six miles per week at a pace slower than 10-minute miles, and even if they ran only one to two days a week, there was still a decrease in mortality compared to nonrunners. Those who ran for this very short amount of time potentially added three years to their life span. There were 55,137 participants ranging in age from 18 to 100 years old.

An accompanying editorial to this study noted that more than 50 percent of people in the United States do not meet the current recommendation of at least 30 minutes of moderate exercise per day (5).

Reduce animal protein

A long-standing paradigm has been that we need to eat sufficient animal protein. However, cracks have developed in this theory, especially as it relates to longevity.

In an observational study using NHANES III data, results show that those who ate a high-protein diet (greater than 20 percent of calories from protein) had a twofold increased risk of all-cause mortality, a four-times increased risk of cancer mortality, and a four-times increased risk of dying from diabetes (6). This was over a considerable duration of 18 years and involved almost 7,000 participants ranging in age at the start of the study from 50 to 65.

However, this did not hold true if the protein source was plants. In fact, a high-protein plant diet may reduce the risks, not increase them. The reason, according to the authors, is that animal protein may increase insulin growth factor-1 and growth hormones that have detrimental effects on the body.

The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein once a week or less had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (7). This was an observational trial with over 73,000 participants and a median age of 57 years old.

Reduce systemic inflammation

In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ longevity (8). In fact, if participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.

The good news is that inflammation can be improved significantly with lifestyle changes.

The takeaway from this study is that IL-6 is a relatively common biomarker for inflammation that can be measured with a simple blood test offered by most major laboratories. This study involved 3,044 participants over the age of 35 who did not have a stroke, heart attack or cancer at the beginning of the study.

The bottom line is that, although genetics are important for longevity, so too are lifestyle choices. A small amount of exercise and replacing animal protein with plant protein can contribute to a substantial increase in healthy life span. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Therefore, why not have a discussion with your doc-tor about testing to see if you have an elevated IL-6? Lifestyle modifications may be able to reduce these levels.

References:

(1) nia.nih.gov. (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) J Am Coll Cardiol. 2014;64:472-481. (5) J Am Coll Cardiol. 2014;64:482-484. (6) Cell Metab. 2014;19:407-417. (7) JAMA Intern Med. 2013;173:1230-1238. (8) CMAJ. 2013;185:E763-E770.

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. 

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Fruit, like these Sumo Citrus, is a good source of fiber. Photo by Heidi Sutton
Modest lifestyle changes have a resounding effect

By David Dunaief, M.D.

Dr. David Dunaief

We can significantly reduce the occurrence of heart disease, the number one killer in the United States, by making modest lifestyle changes.

According to the Centers for Disease Control and Prevention, there are 790,000 heart attacks annually and 210,000 of these occur in those who’ve already had a first heart attack (1). Here, I will provide specifics on how to make changes to protect you and your family from heart disease, regardless of family history.

The evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Changes that garner a big bang for your buck include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Chocolate effect

Chocolate lovers, this study is for you! Preliminary evidence shows that two pieces of chocolate a week may decrease the risk of a heart attack by 37 percent, compared to those who consume less (2). However, the authors warned against the idea that more is better. In fact, high fat and sugar content and calorically dense aspects may have detrimental effects when consumed at much higher levels. There is a fine line between potential benefit and harm. The benefits may be attributed to micronutrients referred to as flavonols.

I usually recommend that patients have one to two squares – about one-fifth to two-fifths of an ounce – of dark chocolate daily. Who says prevention has to be painful?

Role of fiber

Fiber has a dose-response relationship to reducing risk. In other words, the more fiber intake, the greater the reduction in risk. In a meta-analysis of 10 studies, results showed for every 10-gram increase in fiber, there was a corresponding 14 percent reduction in the risk of a cardiovascular event and a 27 percent reduction in the risk of heart disease mortality (3). The authors analyzed data that included over 90,000 men and 200,000 women.

The average American consumes about 16 grams per day of fiber (4). The Academy of Nutrition and Dietetics recommends 14 grams of fiber for each 1,000 calories consumed, or roughly 25 grams for women and 38 grams for men (5). Therefore, we can significantly reduce our risk of heart disease if we increase our consumption of fiber to reach the recommended levels. Good sources of fiber are whole grains and fruits.

Omega-3 fatty acids

In a study with over 45,000 men, there were significant reductions in coronary heart disease with omega-3 PUFAs. Both plant-based and seafood-based omega-3s showed these effects (7). Good sources of omega-3s from plant-based sources include nuts, such as walnuts, and ground flaxseed.

Your ultimate goal should be to become “heart attack proof,” a term used by Dr. Sanjay Gupta and reinforced by Dr. Dean Ornish. This requires a plant-based diet. The more significant the lifestyle modifications you make, the closer you will come to achieving this goal. But even modest changes in diet will result in significant reductions in risk.

Legumes’ impact

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (NHEFS), legumes reduced the risk of coronary heart disease by a significant 22 percent. Those who consumed four or more servings per week, compared to those who consumed less than one serving, saw this effect. The legumes used in this study included beans, peas and peanuts (6). There were over 9,500 men and women involved, spanning 19 years of follow-up. I recommend that patients consume at least one to two servings a day, or 7 to 14 a week. Imagine the impact that would have, compared to the modest four servings per week used to reach statistical significance.

References:

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (5) eatright.org. (6) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (7) Circulation. 2005 Jan 18;111(2):157-164.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

Biomarkers for inflammation

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

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

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

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

Statin effect

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

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

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

Exercise

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

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

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

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

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

References:

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

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

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Lifestyle changes can reduce your risk

By David Dunaief, M.D.

Dr. David Dunaief

Aneurysms are universally feared; they can be lethal and most times are asymptomatic (without symptoms). Yet aneurysms are one of the least well-covered medical disorders in the press. There are numerous types of aneurysms, most of which are named by their location of occurrence, including abdominal, thoracic and cerebral (brain). In this article, I will discuss abdominal aortic aneurysms, better known as a “triple-A,” or AAA. Preventing any type of aneurysm should be a priority.

What is an AAA? It is an increase in the diameter of the walls of the aorta in one area, in this case, the abdomen. The aorta is the “water main” for supplying blood to the rest of the body from the heart. Abnormal enlargement weakens the walls and increases the risk that it may rupture. If the aorta ruptures, it causes massive hemorrhaging, or bleeding, and creates a substantial likelihood of death.

The exact incidence of aneurysms is difficult to quantify, since some people may die due to its rupture without having an autopsy; however, estimates suggest that they occur in 4 to 9 percent of the population (1).

The cause of AAA is not known, but it is thought that inflammation and oxidative stress play an important role in weakening smooth muscle in the aorta (2). The consequence of this is an abnormally enlarged aorta.

People who are at highest risk for aneurysms are those over age 60 (3). Other risk factors include atherosclerosis, or hardened arteries; high blood pressure; race (Caucasian); gender (male); family history; smoking; and having a history of aneurysms in other arteries (4). Some of these risk factors are modifiable, such as atherosclerosis, high blood pressure and smoking.

Men are more than four times more likely to have an AAA (5). Though males are at a higher risk, women are at a higher risk of having an AAA rupture (6). So, gender is important for differentiating the incidence, but also the risk of severity.

Is it important to get screened?

The short answer is yes it is important, especially if you have risk factors. You should talk to your physician. Although some people do experience nondescript symptoms, such as pain in the abdomen, back or flank pain, the majority of cases are asymptomatic (4). A smaller AAA is less likely to rupture and can be monitored closely with noninvasive diagnostic tools, such as ultrasound and CT scan.

Sometimes cost is a question when it comes to screening, but a recent study showed unequivocally that screening ultimately reduces cost, because of the number of aneurysms that are identified and potentially prevented from rupturing (7).

What are the treatments?

There are no specific medications that prevent or treat abdominal aortic aneurysms. Medications for treating risk factors, such as high blood pressure, have no direct impact on an aneurysm’s size or progression. But the mainstay of treatment is surgery to prevent rupture. Two surgical techniques may be utilized. One approach is the endovascular repair (EVAR), which is minimally invasive, and the other is the more traditional open surgery (8). A comparison of these approaches in a small randomized controlled trial had similar outcomes: a mortality rate of 25 percent. This was considered a surprisingly good statistic.

The good news is that surgery has resulted in a 29 percent reduction in rupture of the AAA (9). When using the minimally invasive EVAR technique mentioned above, the specialist who performs the surgery may make a difference. A study’s results showed that surgeons had better outcomes, in terms of mortality rates and length of hospital stay, compared to interventional radiologists and cardiologists (10). This was a retrospective (looking in the past) study, which is not the strongest type of trial.

When to watch and wait and when to treat is a difficult question; surgery is not without its complications, and risk of death is higher than many other surgeries. AAA size is the most important factor. In women, AAAs over 5.0 cm may need immediate treatment, while in men, those over 5.5 cm may need immediate treatment (11). Smaller AAAs, however, are trickier.

The growth rate is important, so patients with this type of aneurysm should have an ultrasound or CT scan every six to 12 months. If you have an aneurysm, have a discussion with your physician about this.

Lifestyle changes

One of the most powerful tools against AAA is prevention; it avoids the difficult decision of how to best avoid rupture and the complications of surgery itself. Lifestyle changes are a must. They don’t typically have dangerous side effects, but rather potential side benefits. These lifestyle changes include smoking cessation, exercise and dietary changes.

Smoking cessation

Studies have shown that cigarette smoking and other forms of tobacco use appear to increase your risk of aortic aneurysms.

Smoking has the greatest impact because it directly impacts the occurrence and size of an AAA. It increases risk of medium-to-large size aneurysms by at least fivefold. One study found that smoking was responsible for 78 percent of aortic aneurysms larger than 4 cm (12). Remember, size does matter in terms of rupture risk. So for those who smoke, this is a wake-up call.

Impact of fruit

A simple lifestyle modification with significant impact is increasing your fruit intake. The results of two prospective (forward-looking) study populations, Cohort of Swedish Men and the Swedish Mammography Cohort Study, showed that consumption of greater than two servings of fruit a day decreased the risk of an AAA by 25 percent (13). If you do have an AAA, this same amount of fruit also decreased the risk of AAA rupture by 43 percent. This study involved over 80,000 men and women, ages 46 to 84, with a follow-up of 13 years.

The authors believe that fruit’s impact may have to do with its antioxidant properties; it may reduce the oxidative stress that can cause these types of aneurysms. Remember, the quandary has been when the benefit of surgery outweighs the risks, in terms of preventing rupture. This modest amount of fruit on a daily basis may help alleviate this quandary.

So what have we learned? Screening for AAA may be very important, especially as we age and if we have a family history. Surgery results to prevent rupture are similar, regardless of the type. However, keep in mind that surgery for AAA has a significant mortality risk. At the end of the day, lifestyle changes, including smoking cessation and increased fruit intake, are no-brainers.

References: (1) Ann Intern Med. 2001;134(3):182. (2) Arterioscler Thromb Vasc Biol. 2007;27:461–469. (3) J Vasc Surg. 1999;30(6):1099. (4) uptodate.com. (5) Arch Intern Med. 2000;160(10):1425. (6) J Vasc Surg. 2006;43(2):230. (7) 2012 BMJ Publishing Group. (8) Ann Surg. 2013 online Apr 1. (9) J Vasc Surg. 2009;49(3):543. (10) Annals of Surgery. 2013;258(3):476-482. (11) Lancet. 1998;352(9141):1649. (12) Ann Intern Med. 1997;126(6):441. (13) Circulation. 2013;128:795-802.

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

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