Tags Posts tagged with "Medical Compass"

Medical Compass

A retrospective study showed that one of out every 370 patients who took bisphosphonates to prevent and treat osteoporosis were afflicted with scleritis.
Common medications may affect vision

By David Dunaief

Dr. David Dunaief

When we refer to adverse events with medications, we usually focus on systemic consequences. However, we rarely address the fact that eyes can be adversely affected by medications. There have been several studies that illustrate this very important point.

It is vital that we recognize the symptoms of eye distress. Some of these may indicate ophthalmic emergencies. The medications studied include common therapeutics, such as bisphosphonates, aspirin, a class of antibiotics called fluoroquinolones and a migraine therapy. I will explain the symptoms to be cognizant of with each.

The impact of bisphosphonates

The class of drugs known as bisphosphonates is a mainstay for the prevention and treatment of osteoporosis. Adverse news about bisphosphonates typically focuses on atypical femur fractures and osteonecrosis (death of part of the jawbone), not on an ocular effect. However, in a large retrospective study (looking at past data), oral bisphosphonates were shown to increase the risk of uveitis and scleritis, both inflammatory eye diseases, by 45 and 51 percent, respectively (1). One out of every 1,100 patients treated with the drugs suffered from uveitis, and one out of every 370 patients treated suffered from scleritis.

Why is this important? The consequences of not treating uveitis can lead to complications, such as glaucoma and cataracts. The symptoms of uveitis typically include eye redness, pain, light sensitivity, decreased vision and floaters (2).

For scleritis, the symptoms are severe pain that radiates to the face and around the orbit, with worsening in the evening and morning and with eye movements (3). Uveitis affects the iris and ciliary body (fluid inside the eye and muscles that help the eye focus), while scleritis affects the sclera, or white part of the eye.

These adverse eye events occurred only in first-time users. The authors believe the mechanism of action may involve the release of inflammatory factors by the bisphosphonates.

Aspirin yet again, maybe not?

It seems aspirin can never get a break. It has been implicated in gastrointestinal bleeds and hemorrhagic (bleeding) strokes. The European Eye Study also suggests that aspirin increases the risk of age-related macular degeneration (4). The primary effect is seen, unfortunately, with wet AMD, which is the form that leads to central vision loss. The risk of wet AMD is directly related to the frequency of aspirin use. When aspirin is used at least once a week, but not daily, the risk is increased by 30 percent.

But, this is not the complete story. The researchers found that there was no increase in wet AMD in patients over 85 years old. They also found that the potential for angina (chest pain) and cardiovascular deaths was not eliminated.

This study was large and retrospective in design, and it included fundoscopic (retinal) pictures, making the results more reliable. The authors recommend that AMD patients not use aspirin for primary prevention, meaning without current cardiovascular disease. However, aspirin use for secondary prevention — for those with heart disease or a previous stroke — the benefits of the medication outweigh the risks.

In fact, the Physician Health Study, a randomized controlled study published in 2001, found that aspirin may even reduce the risk of AMD (5). In yet another study, the Age Related Eye Disease Study (AREDS), aspirin seemed to have a protective effect when it came to AMD (6). Therefore, please do not stop taking aspirin if you have cardiovascular disease since the results, at best, are mixed when it comes to AMD.

However, what is more relevant is that aspirin has been shown to reduce the risk of vascular mortality by 15 percent, stroke by 25 percent and overall mortality by 10 percent (7). While the jury is still out on the effect of aspirin on AMD, there is the ASPREE-AMD study that was started in 2017 to help answer the question of low-dose aspirin’s, 100 mg daily, impact on AMD risk.

The role of antibiotics: fluoroquinolones in retinal detachment

Fluoroquinolones may have toxic effects on the synthesis of collagen and on connective tissue, potentially resulting in retinal detachments and Achilles tendon rupture. This is a common class of antibiotics used to treat acute diseases, such as urinary tract infections and upper respiratory infections.

In an epidemiologic study, these drugs were shown to increase the risk of retinal detachment by 4.5 times (8). Common fluoroquinolones include ciprofloxacin (Cipro), levofloxacin (Levaquin) and gatifloxacin (Tequin). Although it sounds like an impressive number, it’s not a common occurrence. It takes the treatment of 2,500 patients before one patient is harmed. Also, this was only noticed in current users, not in recent or past users. However, it is a serious condition.

Retinal detachment is an ophthalmic emergency, and patients need to be evaluated by an ophthalmologist urgently to avoid irreparable damage and vision loss. Retinal detachments are treatable with surgery. Best results are seen within 24 hours of symptoms, which include many floaters, bright flashes of light in the periphery and a curtain over the visual field (9). Fortunately, retinal detachments usually only affect one eye.

Migraine medication

Topiramate (Topomax) is a drug used to treat and prevent migraines. In a case-control (with disease vs. without disease) study, topiramate increased the risk of glaucoma in current users by 23 percent. The risk more than doubled to 54 percent in first-time users (10). The mechanism of action may be related to the fact that topiramate increases the risk of intraocular pressure.

It is important to be aware that medications not only have systemic side effects, but ocular ones as well. Many of these medications cause adverse effects that require consultation with an ophthalmologist, especially with aspirin, since the cardiovascular benefits seem to outweigh any negative impacts on AMD with people who have cardiovascular disease. If you have ocular symptoms related to medications, contact your physician immediately.

References:

(1) CMAJ. 2012 May 15;184(8):E431-434. (2) www.mayoclinic.org. (3) www.uptodate.com. (4) Ophthalmology. 2012;119:112-118. (5) Arch Ophthalmol. 2001;119:143-149. (6) Medscape.com. (7) Lancet. 2009;373:1849-1860. (8) JAMA. 2012;307:1414-1419. (9) www.ncbi.nlm.nih.gov. (10) Am J Ophthalmol. 2012 May;153(5):827-830.

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.

One simple lifestyle change is to make certain that those susceptible to gout attacks remain hydrated and consume plenty of fluids. Stock photo
Most risk factors are modifiable

By David Dunaief, M.D.

Dr. David Dunaief

Gout is thought of as an inflammatory arthritis. It occurs intermittently, affecting the joints, most commonly the big toe. The symptoms are acute (sudden onset) and include extremely painful, red, swollen and tender joints. In terms of symptoms, if you have ever had kidney stones, gouty arthritis is just as painful.

Uric acid (or urate) levels are directly related to the risk of gout attacks. As uric acid levels increase, there is a greater chance of urate crystal deposits in the joints. Although, and unfortunately, some patients can still experience gout attacks without high levels of uric acid.

This disease affects approximately 8.3 million people in the United States (1). This number has doubled since the 1960s. Men between 30 and 50 years old are at much higher risk for their first attack (2). For women, most gout attacks occur after menopause.

There are a number of potential causes of gout, as well as ways to prevent and treat it. The most common contributors include drugs, such as diuretic use; alcohol intake; uncontrolled hypertension (high blood pressure); obesity; and sweetened beverage and fructose intakes (3). Though heredity plays a role, these risk factors are modifiable.

The best way to prevent and treat gout is by modifying medications and lifestyle. One simple lifestyle change is to make certain, just like with kidney stone prevention, that those susceptible to gout attacks remain hydrated and consume plenty of fluids.

Just like there are medications that may cause gout, there are also medications that can treat and help prevent gout. If you do get a gout attack, NSAIDs such as indomethacin or steroids such as a Medrol pack help treat the symptoms. In terms of prevention, allopurinol helps to reduce the risk of a gout attack.

I thought we might look at gout by using a case study. I had a patient who had started a nutrient-dense, plant-based diet. Within two weeks, she had a gout episode. Initially, it was thought that her change in diet with increased plant purines might have been an exacerbating factor. Purines are substances that raise the level of uric acid. So, it is not surprising that foods with containing purines might substantiate a gout attack. However, not all purines equally raise uric acid levels.

Animal versus plant proteins

In a case-crossover (epidemiologic forward-looking) study, it was shown that purines from animal sources increase our levels of purines far more than those from plant sources (4). The risk of a gout incident was increased approximately 241 percent in the group consuming the highest amount of animal products, whereas the risk of gout was still increased for those consuming plant-rich purine substances, but by substantially less: 39 percent.

The authors believe that decreasing the use of purine-rich foods, especially from animal sources, may decrease the risk of incidences and recurrent episodes of gout. Plant-rich diets are the preferred method of consuming proteins for patients who suffer gout attacks, especially since nuts and beans are excellent sources of protein and many other nutrients.

In another study, meats — including red meat, pork and lamb — increased the risk of gout, as did seafood (5). However, purine-rich plant sources did not increase risk of gout. Low-fat dairy actually decreased the risk of gout by 21 percent. The study was a large observational study involving 49,150 men over a duration of 12 years.

There are several more studies indicating and reaffirming that plant foods do not increase the risk of gout attacks. The Mayo Clinic also suggests that plants do not increase the risk of gout. When considering my patient’s circumstances, it was unlikely that her switch to a nutrient-dense, plant-rich diet had increased her risk of gout.

Diuretics (water pills)

My patient was on a diuretic called hydrochlorothiazide for hypertension (high blood pressure). There are several medications thought to increase the risk of gout, including diuretics and chronic use of low-dose aspirin. In the ARIC study, patients who used diuretics to control blood pressure were at a 48 percent greater risk of developing gout than nonusers (6). In fact, nonusers had a 36 percent decreased risk of developing gout. This study involved 5,789 participants and had a fairly long duration of nine years. The longer the patient is treated with a diuretic, the higher the probability they will experience gout. It is likely that my patient’s diuretic contributed to her gout episode.

Vitamin C

Vitamin C may reduce gout risk. In the Physicians Follow-up Study, a 500-mg daily dose of vitamin C decreased levels of uric acid in the blood (9). However, be careful with vitamin C supplementation because it can increase the risk of kidney stones.

Medical conditions

There are a number of medical conditions that may impact the risk of gout. These include uncontrolled high blood pressure, diabetes and high cholesterol (7). My patient’s high blood pressure was under control, but she also had diabetes and high cholesterol. These disorders may have also contributed.

Obesity

Obesity, like smoking, seems to have its impact on almost every disease. In the CLUE II study, obesity was shown to not only increase the risk of gout but also to accelerate the age of onset (8). Those who were obese experienced gout three years earlier than those who were not. Even more striking is the fact that those who were obese in early adulthood had an 11-year earlier onset of gout. The study’s duration was 18 years. My patient was obese and had just started to lose some weight before the gout occurred.

Prevention

The key to success with gout lies with prevention. Patients who do get gout writhe in pain. Luckily, there are modifications that significantly reduce the risks. They involve very modest changes, such as not using medications called diuretics in patients with a history of gout; losing weight for obese patients; and substituting more plant-rich foods for meats and seafood. Increasing levels of uric acid may be a useful biomarker for indicating an increased risk of gouty arthritis attacks. However, gout attacks do occur without a rise in uric acid levels, so it is not a perfect. Although the cause of gout may be apparent to you, always check with your doctor before changing your medications or making significant lifestyle modifications, as we have learned from this case study of my patient.

References:

(1) Arthritis Rheum. 2011 Oct;63(10):3136-3141. (2) Arthritis Res Ther. 2006;8:Suppl 1:S2. (3) Am Fam Physician. 2014 Dec 15;90(12):831-836. (4) Ann Rheum Dis. online May 30, 2012. (5) NEJM 2004;350:1093-1103. (6) Arthritis Rheum. 2012 Jan;64(1):121-129. (7) www.mayoclinic.com. (8) Arthritis Care Res (Hoboken). 2011 Aug;63(8):1108-1114. (9) J Rheumatol. 2008 Sep;35(9):1853-1858.

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.

According to a recent study, excessive dietary iron intake may increase the risk of age-related macular degeneration. Stock photo
Too much iron can damage the body

By David Dunaief, M.D.

Dr. David Dunaief

Iron is contained in most of the foods that we eat. It is needed for proper functioning of the body and plays an integral role in such processes as DNA synthesis and adenosine triphosphate (ATP) production, which provides energy for cells (1). It is very important to maintain iron homeostasis, or balance.

When we think of iron, we associate it with reducing fatigue and garnering energy. In fact, many of us think of the ironman triathlons — endurance and strength come to mind. If it’s good for us, then the more we get the better. Right? It depends on the circumstances. But for many of us, this presumption is not grounded in reality.

Iron in excess amounts is dangerous. It may contribute to a host of diseases, including diabetes, diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, Parkinson’s disease and even heart disease. These diseases are perpetuated because when we have excess iron it may cause reactive oxygen species, or free radicals, which cause breakdown of DNA and tissues, ironically, the very things that iron homeostasis tends to preserve (2).

So what helps us differentiate between getting enough iron and iron overload? It is a good question and depends on the type of iron we ingest. There are two main types: heme iron and nonheme iron. Dietary heme, or blood, iron primarily comes from red meat and is easily absorbed into the gut. Dietary nonheme iron comes from other sources, such as plants and fortified foods, which are much more difficult sources to absorb. By focusing on the latter source of dietary iron, you may maintain homeostasis, since the gut tends to absorb 1 to 2 mg of iron but also excretes 1 to 2 mg of iron through urine, feces and perspiration.

Not only does it matter what type of iron we consume but also the population that ingests the iron. Age and gender are critical factors. Let me explain. Women of reproductive age, patients who are anemic and children may require more iron. However, iron overload is more likely to occur in men and postmenopausal women because they cannot easily rid the body of excess iron.

Let’s investigate some of the research that shows the effects of iron overload on different chronic diseases.

Impact on diabetes

In a meta-analysis (a group of 16 studies), results showed that both dietary heme iron and elevated iron storage (ferritin) may increase the risk of type 2 diabetes (3). When these ferritin levels were high, the risk of diabetes increased 66 to 129 percent. With heme iron, the group with the highest levels had a 39 percent increased risk of developing diabetes. There were over 45,000 patients in this analysis. You can easily measure ferritin with a simple blood test. Also these levels are modifiable through blood donation and avoidance of heme iron, thus reducing the risk of iron overload.

Diabetic retinopathy

Diabetic retinopathy is a complication of diabetes that occurs when glucose, or sugar, levels are not tightly controlled. It affects the retina, or the back of the eye. Iron excess and its free radicals can have detrimental effects on the retina (4). This is potentially caused by oxidative stress resulting in retinal tissue damage (5).

So how does iron relate to uncontrolled glucose levels? In vitro studies (preliminary lab studies) suggest that high glucose levels may perpetuate the breakdown of heme particles and subsequently raise the level of iron in the eye (6). In fact, those with diabetic retinopathy tend to have iron levels that are 150 percent greater than those without the disease (7). Diets that are plant based and, therefore, nutrient dense are some of the most effective ways to control glucose levels and avoid diabetic retinopathy.

Age-related macular degeneration

Continuing with the theme of retinal damage, excessive dietary iron intake may increase the risk of AMD according to the Melbourne Collaborative Cohort Study (8). AMD is the number one cause of blindness for people 65 and older. People who consumed the most iron from red meat increased their risk of early AMD by 47 percent. However, due to the low incidence of advanced AMD among study participants, the results for this stage were indeterminate.

I have been frequently asked if unprocessed red meat is better than processed meat. Well, this study showed that both types of red meat were associated with an increased risk. This was a large study with over 5,000 participants ranging in age from 58 to 69.

Cardiovascular disease

Though we have made considerable headway in reducing the risk of cardiovascular disease and even deaths from these diseases, there are a number of modifiable risks that need to be addressed. One of these is iron overload. In the Japan Collaborative Cohort, results showed that men who had the highest amount of dietary iron were at a 43 percent increased risk of stroke death, compared to those who ate the least amounts (9). And overall increased risk of cardiovascular disease death, which includes both heart disease and stroke, was increased by 27 percent in men who consumed the most dietary iron. There were over 23,000 Japanese men who were between the ages of 40 to 79 that were involved in this study.

In conclusion, we should focus on avoiding heme iron, especially for men and postmenopausal women. Too much iron creates a plethora of free radicals that damage the body. Therefore, the best way to circumvent the increased risk of chronic diseases with iron overload is prevention. Significantly decreasing red meat consumption and donating blood on a quarterly basis, assuming that one is not anemic, may be the most effective strategies for not falling into the trap of iron overload.

References:

(1) Proc  Natl  Acad  Sci USA. 1997;94:10919-10924. (2) Clin Haematol. 1985;14(1):129. (3) PLoS One. 2012;7(7):e41641. (4) Methods Enzymol. 1990;186:1-85. (5) Rev Endocr Metab Disord. 2008;9(4):315-327. (6) Biophys Chem. 2003;105:743-755. (7) Indian J Ophthalmol. 2004;52:145-148. (8) Am J Epidemiol. 2009;169(7):867-876. (9) J Epidemiol. 2012;22(6):484-493. Epub 2012 Sept 15.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

5) Vitamin D deficiency may contribute to cardiovascular disease.

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

Saturated fat

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

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

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

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

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

Fish oil

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

Fiber

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

Diet soda

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

Vitamin D

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

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

References:

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

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

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.

Different types of exercise have different impacts

By David Dunaief, M.D.

Dr. David Dunaief

Mild cognitive impairment (MCI) is one of the more common disorders that occurs as we age. But age is not the only determinant. There are a number of modifiable risk factors. MCI is feared, not only for its own challenges but also because it may lead to dementia, with Alzheimer’s disease and vascular dementia being the more common forms. Prevalence of MCI may be as high as one-in-five in those over age 70 (1). It is thought that those with MCI may have a 10 percent chance of developing Alzheimer’s disease (2).

Since there are very few medications presently that help prevent cognitive decline, the most compelling questions are: What increases risk and what can we do to minimize the risk of developing cognitive impairment? These are the important questions.

Many chronic diseases and disorders contribute to MCI risk. These include diabetes, heart disease, Parkinson’s disease and strokes. If we can control these maladies, we may reduce the risk of cognitive decline. This involves making lifestyle modifications such as exercise and diet. We know that we can’t stop aging, but we can age gracefully.

Heart disease’s impact

Although we have made great strides, heart disease continues to be prevalent in America. In an observational study, results demonstrated that those suffering from years of heart disease are at a substantial risk of developing MCI (3). The study involved 1,450 participants who were between the ages of 70 and 89 and were not afflicted by cognitive decline at the beginning of the study. Patients with a history of cardiac disease had an almost two times greater risk of developing nonamnestic MCI, compared to those individuals without cardiac disease. Women with cardiac disease were affected even more, with a three times increased risk of cognitive impairment.

Nonamnestic MCI affects executive functioning — decision-making abilities, spatial relations, problem-solving capabilities, judgments and language. It is a more subtle form of impairment that may be more frustrating because of its subtlety. It may lead to vascular dementia and may be a result of clots. This gives us yet another reason to treat and prevent cardiac disease.

Stroke location vs. frequency

Not surprisingly, stroke may have a role in cognitive impairment. Stroke is also referred to as a type of vascular brain injury. But what is surprising is that in a study, results showed that the location of the stroke was more relevant than the frequency or the multitude of strokes (4). If strokes occurred in the cortical and subcortical gray matter regions of the brain, executive functioning and memory were affected, respectively. Thus, the locations of strokes may be better predictors of subsequent cognitive decline than the number of strokes. Clinically silent strokes that were found incidentally by MRI scans had no direct effect on cognition, according to the authors.

Exercise’s effects

Studies have shown that aerobic exercise improves brain function. Stock photo

Exercise may play a significant role in potentially preventing cognitive decline and possibly even improving MCI in patients who have the disorder. Interestingly, different types of exercise have different effects on the brain. Aerobic exercise may stimulate one type of neuronal development, while resistance training or weight lifting another.

In an animal study involving rats, researchers compared aerobic exercise to weight lifting (5). Weight lifting was simulated by attaching weights to the tails of rats while they climbed ladders. Both groups showed improvements in memory tests, however, there was an interesting divergence.

With aerobic exercise, the level of the protein BDNF (brain-derived neurotrophic factor) increased significantly. This is important, because BDNF is involved in neurons and the connections among them, called synapses, related mostly to the hippocampus, or memory center. The rats that “lifted weights” had an increase in another protein, IGF (insulin growth factor), that promotes the development of neurons in a different area of the brain. The authors stressed the most important thing is to exercise, regardless of the type.

In another study that complements the previous study, women were found to have improved spatial memory when they exercised — either aerobic or weight lifting (6). Interestingly, verbal memory was improved more by aerobic exercise than by weight lifting. Spatial memory is the ability to recall where items were arranged, and verbal memory is the ability to recall words. The authors suggest that aerobic exercise and weight lifting affect different parts of the brain, which corroborates the animal study findings above.

This was a randomized controlled trial that was six months in duration and involved women, ages 70 to 80, who had MCI at the trial’s start. There were three groups in the study: aerobic, weight lifting and stretching and toning. Those who did stretches or toning alone experienced deterioration in memory skills over the same period.

Here is the catch with exercise: We know exercise is valuable in preventing disorders like cardiovascular disease and cognitive decline, but are Americans doing enough? A Centers for Disease Control and Prevention report claims the majority of the adult population is woefully deficient in exercise: Only about 1 in 5 Americans exercise regularly, both using weights and doing aerobic exercise (7).

Diet’s effects

Several studies show that the Mediterranean diet helps prevent MCI and possibly prevents conversion from MCI to Alzheimer’s (8, 9). In addition, a study showed that high levels of carbohydrates and sugars, when compared to lower levels, increased the risk of cognitive decline by more than three times (5). The authors surmise that carbohydrates have a negative impact on insulin and glucose utilization in the brain.

Cognitive decline is a disorder that should be taken very seriously, and everything that can be done to prevent it should be utilized. Though the number of Americans exercising regularly is woefully deficient, the silver lining is that there is substantial room for improvement. Exercise has potentially positive effects on neuron growth and development. We need more campaigns like the NFL’s Play 60, which entices children to be active at least 60 minutes every day, but we also need to target adults of all ages. Let’s not squander the opportunity to reduce the risk of MCI, a potentially life-altering disorder.

References: (1) Ann Intern Med. 2008;148:427-434. (2) uptodate.com. (3) JAMA Neurol. 2013;70:374-382. (4) JAMA Neurol. 2013;70:488-495. (5) J Alzheimers Dis. 2012;32:329-339. (6) J Aging Res. 2013;2013:861893. (7) Morb Mortal Wkly Rep. 2013;62:326-330. (8) Neurology 2013;80:1684-1692. (9) Arch Neurol. 2009 Feb.;66:216-225.

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.

EAT YOUR FRUITS AND VEGGIES: Studies have shown that eating five servings or more of fruits and vegetables daily can reduce your risk of cardiovascular disease. Stock photo
Cardiovascular disease is pervasive but preventable

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is so pervasive that men who are 40 years old have a lifetime risk of 49 percent. In other words, about half of men will be affected by heart disease. The statistics are better for women, but they still have a staggering 32 percent lifetime risk at age 40 (1).

The good news is that heart disease is on the decline due to a number of factors, including better awareness in lay and medical communities, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. Heart disease is something that is eminently preventable.

Heart disease risk factors

Risk factors include obesity, high cholesterol, high blood pressure, smoking and diabetes. Unfortunately, both obesity and diabetes are on the rise. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2). However, high blood pressure, high cholesterol and smoking have declined (3).

Of course, family history also contributes to the risk of heart disease, especially with parents who experienced heart attacks before age 60, according to the Women’s Health Study and the Physician’s Health Study (4). Inactivity and the standard American diet, rich in saturated fat and calories, also contribute to heart disease risk (5). The underlying culprit is atherosclerosis (fatty streaks in the arteries).

The newest potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (6). A normal resting heart rate is usually between 60 and 100 bpm. Thus, you don’t have to have a racing heart rate, just one that is high-normal. All of these risk factors can be overcome, even family history.

The role of medication

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. The compliance with blood pressure medications has increased over the last 10 years from 33 to 50 percent, according to the American Society of Hypertension.

In terms of lipids, statins have played a key role in primary prevention. Statins are effective at not only lowering lipid levels, including total cholesterol and LDL — the “bad” cholesterol — but also inflammation levels that contribute to the risk of cardiovascular disease. The Jupiter trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

The downside of statins is their side effects. Statins have been shown to increase the risk of diabetes in intensive dosing, compared to moderate dosing (7).

Unfortunately, many on statins also suffer from myopathy (muscle pain). I have a number of patients who have complained of muscle pain and cramps. Their goal when they come to see me is to reduce and ultimately discontinue their statins by following a lifestyle modification plan involving diet and exercise. Now I will address the role of lifestyle modification as a powerful ally in this endeavor. There is an abundance of studies showing exciting effects.

Lifestyle effects

There was significant reduction in mortality from cardiovascular disease with participants who were followed for a very long mean duration of 18 years. The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (8). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, most importantly, to achieve them it only required a modest change in diet.

The Nurses’ Health Study shows that these results are also seen in women, with lifestyle modification reducing the risk of sudden cardiac death (SCD). Many times, this is the first manifestation of heart disease in women. The authors looked at four parameters of lifestyle modification, including a Mediterranean-type diet, exercise, smoking and body mass index. There was a decrease in SCD that was dose dependent, meaning the more factors incorporated, the greater the risk reduction. There was as much as a 92 percent decrease in SCD risk when all four parameters were followed (9). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

Heart risk and decreased sexual function in men

A meta-analysis (group of studies) showed that with lifestyle modifications and medication therapies, the risk of cardiovascular disease was reduced significantly, which appeared to result in improvements in erectile dysfunction (10). The lifestyle modifications included dietary changes and increased physical activity. When statin medications were not included, the risk reduction remained relatively constant, demonstrating the strength of lifestyle changes. This research is important, since those with chronic erectile dysfunction are likely to have heart disease within two to five years, according to the authors.

How do you know that you are reducing your risk of heart disease and how long does it take?

These are good questions that I have been asked by a number of patients. We use cardiac biomarkers, including inflammatory markers like C-reactive protein, blood pressure, cholesterol and body mass index. A cohort (a certain group of people) study helped answer these questions. It studied both high-risk participants and patients with heart disease. The results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life.

Participants followed extensive lifestyle modification: a plant-based, whole foods diet accompanied by exercise and stress management. The results were statistically significant with all parameters measured. The best part is the results occurred over a very short period to time — three months from the start of the trial (11). Many patients I have seen have had similar results.

Ideally, if patient needs to use medications to treat risk factors for heart disease, it is for the short term. For some patients, it may be appropriate to use medication and lifestyle changes together; for others, lifestyle modifications may be sufficient, as long as patients are willing to take an active role.

References: (1) Lancet. 1999;353(9147):89. (2) Diabetes Care. 2010 Feb; 33(2):442-449. (3) JAMA. 2005;293(15):1868. (4) Circulation. 2001;104(4):393. (5) Lancet. 2004;364(9438):93. (6) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (7) JAMA. 2011;305(24):2556-2564. (8) J Nutr. March 1, 2005;135(3):556-561. (9) JAMA. 2011 Jul 6;306(1):62-69. (10) Arch Intern Med. 2011;171(20):1797-1803. (11) Am J Cardiol. 2011;108(4):498-507.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

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

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

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

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

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

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

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

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

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

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

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

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

Wishing you good health in the new year,

David

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

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

Added sugar increases risk of many diseases

By David Dunaief, M.D.

Dr. David Dunaief

We should all reduce the amount of added sugar we consume because of its negative effects on our health. It is recommended that we get no more than 10 percent of our diet from added sugars (1). However, approximately 14 percent of our diet is from added sugars alone (2).

Is all sugar bad for us? The answer is not straightforward. It really depends on the source, and when I mention source, my meaning may surprise you.

We know that white, processed sugar is bad. But I am constantly asked: Which sugar source is better — honey, agave, raw sugar, brown sugar or maple syrup? None are really good for us; they all raise the level of glucose (a type of sugar) in our blood. Forty-seven percent of our added sugar intake comes from processed food, while 39 percent comes from sweetened beverages, according to the most recent report from the Centers for Disease Control and Prevention (2). Sweetened beverages are defined as soft drinks, sports and energy drinks and fruit drinks. Even 100 percent fruit juice can raise our glucose levels. Don’t be deceived because it says it’s natural and doesn’t include “added” sugar.

These sugars increase the risk of, and may exacerbate, chronic diseases such as diabetes, heart disease, high blood pressure, cancer and obesity. This is such a significant problem that municipal legislatures have considered adding warning labels to sweetened drinks (3).

However, I did say that sugar’s source impacts its effect. Most fruits have beneficial effects in preventing disease, including diabetes, and do not raise sugar levels, even in patients with diabetes. It is a myth that whole fruit raises your sugar levels. However, dried fruits, fruit juice and fruit concentrate do raise your sugar levels. Note that sugar extracted from fruit has an effect similar to that of sugar added to foods and sweetened beverages.

Let’s look at the evidence.

Heart disease

When we think of sugar’s effects, heart disease is not usually the first disease that comes to mind. However, results from a 20-year study of 31,000 U.S. adults showed that, when comparing those who consumed the least amount of added sugar (less than 10 percent of calories daily) with those who consumed 10 to 25 percent and those who consumed more than 25 percent of daily calories from sugar, there were significant increases in risk of death from heart disease (4). The added sugar was from foods and sweetened beverages, not from fruit and fruit juices.

This was not just an increased risk of heart disease but an increased risk of cardiovascular death. This is a wake-up call to rein in our sugar consumption.

Obesity and weight gain

Does soda increase obesity risk? An assessment published in PLoS One, a highly respected, peer-reviewed journal, showed that it depends whether studies were funded by the beverage industry or had no ties to any lobbying groups (5). Study results were mirror images of each other: Studies not affiliated with the industry show that soda may increase obesity risk, while studies funded by the beverage industry show there may not be any association.

In studies without beverage industry funding, greater than 80 percent (10 of 12) showed associations between sugary drinks and increased weight or obesity, whereas with the beverage industry-funded studies, greater than 80 percent of them did not show this result (5 of 6). The moral of the story is that patients must be diligent in understanding studies’ funding and, if the results sound odd, they probably are. If this is the case, make sure to ask your doctor about the studies’ findings. Not all studies are equally well designed.

Diabetes and the benefits of fruit

Diabetes requires the patient to limit or avoid fruit altogether. Correct? This may not be true. Several studies may help change the long-standing, commonly held paradigm that fruit should be restricted in patients with diabetes and to prevent development of diabetes.

One study found that whole fruit may reduce the risk of diabetes by reducing inflammation and reducing insulin resistance (6). Specifically, results demonstrated a reduction in the inflammatory biomarker hsCRP. Ultimately, this may result in better glucose control. A potential reason for these impressive results may be the high levels of flavonoids, specifically anthocyanins and flavones. Flavonoids, as a class, are phytochemicals (plant nutrients) that provide pigment to fruits and vegetables and may have substantial antioxidant activities. Substances that are high in these two flavonoids include red grapes, berries, tea and wine.

Another study, a meta-analysis that looked at three large studies, including the Nurses’ Health Study, NHS II, and the Health Professionals Follow-up Study, showed that those who consumed the highest amount of anthocyanins were likely to experience a 15 percent reduction in the development of type 2 diabetes (7). Researchers compared those in the highest quintile of anthocyanin consumption with those in the lowest quintile.

Specifically, at least two servings of blueberries per week were shown to reduce the risk of diabetes by 23 percent, and at least five servings of apples and pears per week were also shown to reduce the risk by 23 percent. These were compared to those who consumed less than one serving per month. This is a small amount of fruit for a significant reduction.

From the same three studies, it was also shown that grapes, bananas and grapefruit reduce the risk of diabetes, while fruit juice and cantaloupe may increase risk (8).

In still another diabetes study, involving those who were newly diagnosed with type 2 diabetes, the risk of increasing glucose levels was no greater in those who consumed more than two servings of fruit per day compared to those who consumed fewer than two servings per day (9). The properties of flavonoids, for example, those found in whole fruit, may also result in anticancer and anticardiovascular disease properties, the opposite of added sugars (10).

Chronic disease incidence and complications from these diseases have skyrocketed in the last several decades. Therefore, any modifiable risk factor should be utilized to decrease our risk. By keeping added sugar to a minimum in our diets, we could make great strides in the fight to maintain our quality of life as we age.

We don’t have to avoid sugar completely; we still can satiate a sweet tooth by eating ripe fruits. Our access to fruit, even off-season, has expanded considerably. The most amazing thing is that fruit may actually reduce the risk of diabetes, something for years we thought might exacerbate it.

References: (1) 2015-2020 Dietary Guidelines for Americans. (2) cdc.gov. (3) reuters.com. (4) JAMA Intern Med. online Feb 03, 2014. (5) PLoS Med. 2013 Dec;10(12):e1001578. (6) J Nutr. 2014 Feb;144(2):202-208. (7) Am J Clin Nutr. 2012 Apr;95(4):925-933. (8) BMJ. online Aug 29, 2013. (9) Nutr J. published online March 5, 2013. (10) Plant Foods Hum Nutr. 2004 Summer;59(3):113-122.

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

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

By David Dunaief, M.D.

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

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

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

Walking with a spring in your step

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

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

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

Mind-body connection

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

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

‘Longevity’ supplement may have negative impact

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

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

Impact on diabetes complications

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

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

Fitness age

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

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

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

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

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

Social

4,908FansLike
1,038FollowersFollow
33SubscribersSubscribe