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Medical Compass

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NSAIDs and acetaminophens are not risk-free

By David Dunaief, M.D.

Dr. David Dunaief

What’s in your medicine cabinet? If you’re like most people, you have your typical “go-tos” for pain relief, fever or inflammation. You might have aspirin or other NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophen (Tylenol). 

Familiar NSAIDs include ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). Over 70 million prescriptions for NSAIDs are written each year in the U.S., and Americans consume more than 30 billion doses, once over-the-counter (OTC) use is factored in (1).

According to a poll of these regular users of OTC NSAIDs, a substantial number — 60 percent — were unaware of their dangerous side effects (2). Acetaminophen is used frequently, as well. On a weekly basis, one quarter of Americans take it. Unfortunately, many think of these drugs as relatively benign. In fact, I find that until I specifically ask about their use, most patients don’t include them in a list of their medications.

NSAID risks

Unfortunately, NSAIDs, according to the Centers for Disease Control and Prevention, are responsible for 7,600 deaths annually and 10 times that number in hospitalizations (3). These are not medications that should be taken lightly. 

NSAIDs increase the risk of several maladies, including heart attacks, gastrointestinal bleeds, exacerbation of diverticular disease, chronic arrhythmias (abnormal heartbeats) and erectile dysfunction. In some instances, the cardiovascular effects can be fatal.

These risks prompted the FDA to strengthen the warning labels on non-aspirin NSAID labels, advising that those taking NSAIDs should immediately seek medical attention if they experience chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech (4).

Adverse side effects of NSAIDs

In a case control study using the UK Primary Care Database, chronic users of NSAIDs between ages 40 and 89 had a significantly increased risk of a serious arrhythmia (abnormal heartbeat) called atrial fibrillation (5).

Interestingly, chronic users were defined as patients who took NSAIDs for more than 30 days. Those patients who used NSAIDs more than 30 days had a 57 percent increased risk of atrial fibrillation. A Danish study reinforces these results after the first month of use (6). This is not very long to have such a substantial risk. For patients who used NSAIDs longer than one year, the risk increased to 80 percent. 

Caution should be used when prescribing NSAIDs or when taking them OTC. Atrial fibrillation is not an easy disease to treat.

NSAIDs also increase the risk of mortality in chronic users. Older patients who have heart disease or hypertension (high blood pressure) and are chronic NSAIDs users are at increased risk of death, according to an observational study (7). Compared to those who never or infrequently used them over about 2.5 years, chronic users had a greater than twofold increase in death due to cardiovascular causes. High blood pressure was not a factor, since the chronic users actually had lower blood pressure. Yet I have seen with my patients that NSAID use can increase blood pressure. 

Is acetaminophen better?

Acetaminophen does not cause gastrointestinal bleeds, arrhythmias and deaths due to cardiovascular events that NSAIDs can. However, the Food & Drug Administration announced in 2011 that acetaminophen should not exceed 325 mg every four to six hours when used as a prescription combination pain reliever (4). The goal is to reduce and avoid severe injury to the liver, which can cause liver failure. 

There is an intriguing paradox with acetaminophen: Hospitals typically dispense regular-strength 325-mg doses of the drug, whereas OTC doses frequently are found in extra-strength 500-mg tablets, and often the suggested dose is two tablets, or 1 gram. At the FDA’s request, Tylenol lowered its recommended daily dosage for extra strength Tylenol to no more than 3 grams a day to lower the risk of liver damage.

I have patients who have exceeded this, thinking that, because it is OTC, this is “safe.” Unfortunately, this is not true and can be dangerous.

The FDA’s recommendations for limiting the dose result from a conglomeration of data. For instance, one study that showed acute liver failure was due primarily to unintentional overdoses of acetaminophen (8). Accidental overdosing is more likely to occur when taking acetaminophen at the same time as a combination sinus, cough or cold remedy that also contains acetaminophen. OTC and prescription cold medications can contain acetaminophen.

Of course, if you already suffer from liver damage or disease, you should consult with your physician before taking any medications.

In order to be aware of potentially adverse events, you have to be your own best advocate and read labels. Remember to tell your physician if you are taking OTC medications.

If you are a chronic user of NSAIDs or acetaminophen because of underlying inflammation, you may find an anti-inflammatory diet, which is usually plant-based, is an effective alternative.

References:

(1) Medscape.com, 2021 Oct 21 (emedicine.medscape.com/article/816117-overview). (2) J Rheumatol. 2005;32;2218-2224. (3) Annals of Internal Medicine, 1997;127:429-438. (4) fda.gov (5) Arch Intern Med. 2010;170(16):1450-1455. (6) BMJ 2011;343:d3450. (7) Am J Med. 2011 Jul;124(7):614-620. (8) Am J Gastroenterol. 2007;102:2459-2463. 

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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Walking regularly can elevate your mood

By David Dunaief

Dr. David Dunaief

If you were tuning into television in the U.S. for the first time, you would imagine we were a society of exercisers. Sports is big business. Ads for workout equipment, sneakers, and athletic clothing abound. And yet, many of us don’t exercise even the minimum to maintain good physical and mental health through adulthood.

As kids, many of us tried to get out of gym class, and as adults, we “want” to exercise, but we “don’t have time.” The result of this is a nation of couch potatoes. I once heard that the couch is the worst deep-fried food. It perpetuates inactivity, especially when watching TV. Even sleeping burns more calories.

I think part of the problem, generally, is that we don’t know what type of exercise is best and how long and frequently to do it. These days, many who depend on gyms, dance studios and other exercise-related facilities for exercise are struggling to find meaningful substitutes.

Well, guess what? There is an easy way to get tremendous benefit with very little time involved. You don’t need expensive equipment, and you don’t have to join a gym. You can sharpen your wits with your feet.

Jane Brody has written in The New York Times’ Science Times about Esther Tuttle. Esther was 99 years old, sharp as a tack and was independently mobile, with no aids needed. She continued to stay active by walking in the morning for 30 minutes and then walking again in the afternoon. The skeptic might say that this is a nice story, but its value is anecdotal at best. 

Well, evidence-based medicine backs up her claim that walking is a rudimentary and simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away. 

Walking has a powerful effect on preserving brain function and even growing certain areas of the brain (1). Walking between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years.

Those participants who had an increase in brain tissue volume had a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants who had a mean age of 78 and were dementia free at the start of the trial. Imagine if you started earlier? 

In yet another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2). 

Even better news is that, if you’re pressed for time or if you’re building up your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile? You’ll be surprised at how much better you will feel — and how much sharper your thinking is.

This is a terrific strategy to get you off the couch or away from your computer. Set an alarm for specific points throughout the day and use that as a prompt to get up and walk, even if only for 15 minutes. The miles will add up quickly. In addition to the mental acuity benefits, this may also help with your psychological health, giving you a mental break from endless Zoom calls and your eyes a break from endless screens.

If you ratchet up the exercise to running, a study showed that mood also improves, mollifying anger (3). The act of running actually increases your serotonin levels, a hormone that, when low, can make people agitated or angry. So, exercise may actually help you get your aggressions out.

Walking has other benefits as well. We’ve all heard about the importance of doing weight-bearing exercise to prevent osteoporosis and osteoporotic fractures. The movie WALL-E even did a spoof on this, projecting a future where people lived in their movable recliners. The result was a human skeletal structure that had receded over the generations from lack of use. Although it was tongue-in-cheek, it wasn’t too far from the truth; if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles. 

So, remember, use your feet to keep your mind sharp and yourself even-tempered. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References:

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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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Which diet has better cardiovascular outcomes?

By David Dunaief, M.D.

Dr. David Dunaief

Despite the great strides we have made in the fight against heart disease, it is still the number one cause of death in the United States. Can we alter this course, or is it our destiny?

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments.

 Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

Do our genes matter?

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It seems to coordinate with modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that this study does not support that. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, potentially by following a plant-rich diet, such as a Mediterranean-type diet.

Can we improve our genetic response with diet?

The New England Journal of Medicine published a study about the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, the risk profile improvement occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two diametrically opposed opinions, split by field. You may be surprised by which group liked it and which did not. Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

Ultimately, even with a genetic proclivity toward cardiovascular disease, we have confirmation that we can alter our cardiovascular destinies. The degree depends on the willingness of the participants.

References:

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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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95 percent found incidentally are benign

By David Dunaief, M.D.

Dr. David Dunaief

More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound (1). Fortunately, most are benign. A small percent, 4 to 6.5 percent, are malignant, with the number varying depending on the study (2). Thyroid nodules are diagnosed more often incidentally on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck, rather than as a consequence of symptoms (3).

There is a conundrum of what to do with a thyroid nodule, especially when it is found incidentally. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (4). While most are asymptomatic, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (5).

FNA biopsy is becoming more common. In a study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (6). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. Though the number of cancers diagnosed has increased, the mortality rate has remained relatively stable over several decades at about 1,500 patients per year (7). Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam.

Evaluating borderline results

As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two techniques to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test.

A meta-analysis (a group of six studies) of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies, but did not do a good job of identifying those who did have cancer (8).

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (9).

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid.

Significance of calcification detected by ultrasound

Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (10). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk.

Good news

As I mentioned above, most thyroid nodules are benign. The results of one study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (11). The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that, after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

Thyroid function may contribute to risk

In considering risk factors, it is important to note that those who had normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (12).

Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. Why the death rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially two of the most common forms, follicular and papillary.

References:

(1) AACE 2013 Abstract 1048. (2) Thyroid. 2005;15(7):708. (3) uptodate.com. (4) AACE 2013 Abstract 1048. (5) thyroid.org. (6) AAES 2013 Annual Meeting. Abstract 36. (7) AACE 2013 Abstract 1048. (8) Cancer. 2011;117(20):4582-4594. (9) J Clin Endocrinol Metab. Online May 12, 2015. (10) Head Neck. 2008 Sep;30(9):1206-1210. (11) JAMA. 2015;313(9):926-935. (12) J Clin Endocrinol Metab. 2006;91(11):4295.

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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Mild dehydration can lead to decreased concentration, subdued  mood, fatigue and headaches

By David Dunaief, M.D.

Dr. David Dunaief

Dehydration typically gets attention during the summer months, when we spend more time outside in the heat. However, during the cooler winter months, it can also be troublesome. Dry heat quickly evaporates moisture in the air, making it hard to stay hydrated.

Complications and symptoms of dehydration can be mild to severe, ranging from constipation, mood changes, headaches and heart palpitations to heat stroke, migraines and heart attacks.

In addition, the dry air can make our throats and sinuses dry, making us uncomfortable and more susceptible to irritations and viruses.

Dehydration is simple to avoid, right? Not necessarily. We may be dehydrated before we’re thirsty. Let’s look at some of the consequences of dehydration and suggestions for avoiding it.

Tension-type migraines

In a review of studies published in the Handbook of Clinical Neurology, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (1). Headache intensity decreased as well.

Heart palpitations

Heart palpitations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise are contributing factors (2). They occur mainly when we don’t hydrate prior to exercise. All we need to do is drink one glass of water prior to exercise and then drink during exercise to avoid palpitations. Though these symptoms are not usually life-threatening, they are anxiety producing for patients.

Heart attacks

The Adventist Health Study, an observational study, showed a dose-response curve for men (3). In other words, group one, which drank more than five glasses of water daily, had the least risk of death from heart disease than group two, which drank more than three glasses of water daily. Those in group three, which drank fewer than two glasses per day, saw the least amount of benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrinogen, a substance that helps clots form.

Decreased concentration

In a study, mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women (4). In this small study the mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

I would also suggest, from my practice experience, hydration prior to exercise.

Staying hydrated

Now we realize we need to stay hydrated, but how do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. 

In a review article, the authors analyzed the data, but did not find adequate studies to suggest that eight glasses is supported in the literature (5). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like Mediterranean or Dietary Approaches to Stop Hypertension (DASH), have a plant-rich focus. A study notes that diets with a focus on fruits and vegetables increases water consumption (6). As you may know, 95 percent of the weights of many fruits and vegetables are attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Remember that salty foods can be dehydrating, including breads and pastries, so try to avoid these.

Are caffeinated drinks dehydrating?

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (7). With moderate amounts of caffeinated beverages, the liquid has a more hydrating effect than its diuretic effect.

Keeping some humidity in the air

To reduce sinus inflammation and dry skin that you can experience with heated air, measure the humidity level in your home with a hygrometer and target keeping it between 30 and 50 percent (8). When the temperature outside drops below 10 degrees F, lower this to 25 percent.

Strategies for adding moisture to the air include using cool mist humidifiers, keeping the bathroom door open after you bathe or shower, and placing bowls of water strategically around your home, including on your stovetop when you cook. If you use a humidifier, take care to follow the manufacturer’s care instructions and clean it regularly.

It is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (9).

References:

(1) Handb Clin Neurol. 2010;97:161-72. (2) my.clevelandclinic.org. (3) Am J Epidemiol 2002 May 1; 155:827-33. (4) J. Nutr. February 2012 142: 382-388. (5) AJP – Regu Physiol. 2002;283:R993-R1004. (6) Am J Lifestyle Med. 2011;5(4):316-319. (7) Exerc Sport Sci Rev. 2007;35(3):135-140. (8) epa.gov (9) Br J Ophthalmol. 2005:89:1298–1301.

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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Elevate your holiday meal by integrating healthy options
Dr. David Dunaief

This year, many of us are considering revising our Thanksgiving meal choices for the first time in generations. These past two years have provided a critical reminder of the importance of managing or reversing chronic diseases. This, coupled with a growing interest in plant-based eating, has prompted many to consider ways to reset the table, so to speak.

What can we do to turn Thanksgiving into a bonanza of good health? Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. 

Carotenoids make up a family of more than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (1).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer, amyotrophic lateral sclerosis (Lou Gehrig’s disease), age-related macular degeneration, and cardiovascular disease — heart disease and stroke. Foods that contain these substances are dark green leafy vegetables, as well as orange, yellow and red vegetables and fruits. 

A simple breast cancer study demonstrates their effects. We know that breast cancer risk is high among U.S.-born women, where the average lifetime risk of getting breast cancer is 12.8 percent (2).

In a meta-analysis of eighteen prospective studies, results show that women who consumed higher levels of carotenoids, such as alpha-carotene, beta-carotene, and lutein and zeaxanthin, had significantly reduced risk of developing estrogen-negative breast cancer (3).

Strategies for healthy holiday eating

Despite the knowledge that healthy eating has long-term positive effects, there are obstacles to healthy eating. Two critical factors are presentation and perception.

Vegetables are often prepared in either an unappetizing way — steamed to the point of no return — or smothered in cheese, negating their benefits, but clearing our consciences.

Many consider Thanksgiving a time to indulge and not think about the repercussions. Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. Why is it so important to change our mindsets? There are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when many gain the predominant amount of weight for the entire year. However, most do not lose the weight they gain during this time (4). If you can fend off weight gain during the holidays, think of the possibilities for the rest of the year.

Also, if you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (5). However, with a little Thanksgiving planning, you can reap significant benefits.

Here are some suggestions to get you thinking about ways to shift the heavy holiday meal paradigm:

Make healthy, plant-based dishes part of the main course. You don’t have to forgo signature dishes, but supplement tradition by adding mouthwatering vegetable-based dishes. One of my favorites is steamed “sweet” vegetables – cauliflower, broccoli, snap peas, onions and garlic. To make it sweet, I steam it in a splash of citrus-infused balsamic vinegar and add sliced apples before steaming. If you want to make this a primary dish, add diced tofu and/or garbanzo beans to make it more filling without overwhelming its delicate sweetness.

Improve vegetable options. Why would you serve vegetables without any seasoning? In my family, we season vegetables and make sauces to drizzle over them.

My 16-year-old nephew, who has never liked cooked vegetables, fell in love with my wife’s roasted Brussels sprouts and broccoli while on vacation this summer. He actually texted her a week later to ask for the recipes. Now, he makes them for himself. Good resources for appealing dishes can be found at PCRM.org, mouthwateringvegan.com, and many other resources.

Replace refined grains. A study in the American Journal of Clinical Nutrition, showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (6). Not only did participants lose subcutaneous fat found just below the skin, but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer.

For even better results, consider substituting riced cauliflower or mashed cauliflower for rice or potatoes. You can purchase frozen riced cauliflower in many grocery stores now. Just be sure to get one that’s unsalted. If you prefer mashed, I have a simple recipe for mashed cauliflower here: www.medicalcompassmd.com/2021/01/09/mashed-cauliflower-recipe-vegan/

Create a healthy environment. Instead of putting out creamy dips, cheese platters and candies as snacks, choose whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.

Offer healthy dessert options. Options might include dairy-free pumpkin pudding and fruit salad.

The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods. Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and that increase your risk for chronic diseases, promote everyone’s health, while maintaining the theme of a traditional festive meal.

References:

(1) Crit Rev Food Sci Nutr 2010;50(8):728–760. (2) SEER Cancer Statistics Review, 1975–2016, National Cancer Institute. (3) Am J Clin Nutr. 2012 Mar; 95(3): 713–725. (4) N Engl J Med 2000; 342:861-867. (5) www.heart.org. (6) Am J Clin Nutr 2010 Nov;92(5):1165-71.

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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Is there a magic bullet to speed the healing process?

By David Dunaief, M.D.

Dr. David Dunaief

Now that many of us are interacting more fully in society, the common cold is becoming common again this fall.

All of us have suffered from the common cold at some point. Most frequently caused by the notorious human rhinovirus, its effects can range from an annoyance to more serious symptoms that put us out of commission for a week or more.

Amid folklore about remedies, there is evidence that it may be possible to reduce the symptoms — or even reduce the duration — of the common cold with supplements and lifestyle management.

I am frequently asked, “How do I treat this cold?” Below, I will review and discuss the medical literature, separating myth from fact about which supplements may be beneficial and which may not.

Zinc

You may have heard that zinc is an effective way to treat a cold. But what does the medical literature say? The answer is a resounding, YES! According to a meta-analysis that included 13 trials, zinc in any form taken within 24 hours of first symptoms may reduce the duration of a cold by at least one day (1) Even more importantly, zinc may significantly reduce the severity of symptoms throughout the infection, improving quality of life. The results may be due to an anti-inflammatory effect of zinc.

One of the studies, which was published in the Journal of Infectious Disease, found that zinc reduced the duration of the common cold by almost 50 percent from seven days to four days, cough symptoms were reduced by greater than 60 percent and nasal discharge by 33 percent (2). All of these results were statistically significant. Researchers used 13 grams of zinc acetate per lozenge taken three-to-four times daily for four days. This translates into 50-65 mg per day.

There are a few serious concerns with zinc. Note that the dose researchers used was well above the maximum intake recommended by the National Institutes of Health, 40 mg per day for adults. This maximum intake number goes down for those 18 and younger (3). Also, note that the FDA has warned against nasal administration through sprays, which has led to permanent loss of smell in some people.

As for the studies, note that not all studies showed a benefit. Also, all of the studies where there was a proven benefit may have used different formulations, delivery systems and dosages, and there is no current recommendation or consensus on what is optimal.

Vitamin C

According to a review of 29 trials with a combined population of over 11,000, vitamin C did not show any significant benefit in prevention, reduction of symptoms or duration in the general population (4). Thus, there may be no reason to take mega-doses of vitamin C for cold prevention and treatment. However, in a sub-group of serious marathon runners and other athletes, there was substantial risk reduction when taking vitamin C prophylactically; they caught 50 percent fewer colds.

Echinacea

After review of 24 controlled clinical trials, according to the Cochrane Database, the jury is still out on the effectiveness of echinacea for treatment of duration and symptoms, but the results are disappointing presently and, at best, are inconsistent (5). There are no valid randomized clinical trials for cold prevention using echinacea. In a randomized controlled trial with 719 patients, echinacea was no better than placebo for the treatment of the common cold (6).

Exercise

People with colds need rest – at least that was the theory. However, a study published in the British Journal of Sports Medicine may have changed this perception. Participants who did aerobic exercise at least five days per week, versus one or fewer days per week, had a 43 percent reduction in the number of days with colds over two 12-week periods during the fall and winter months (7). Even more interesting is that those who perceived themselves to be highly fit had a 46 percent reduction in number of days with colds compared to those who perceived themselves to have low fitness. The symptoms of colds were reduced significantly as well.

Symptom relief

What do I confidently recommend to my patients? If you have congestion or coughing symptoms with your cold, time-tested symptom relief may help. Sitting in a steamy bathroom, which simulates a medical mist tent, can help. Also, dry heat is your enemy. If your home is dry, use a cool mist humidifier to put some humidity back in the air.

Consuming salt-free soups loaded with vegetables can help increase your nutrient intake and loosen congestion. I start with a sodium-free base and add in spices, onions, spinach, broccoli and other greens until it’s more stew-like than soup-like.

Caffeine-free hot teas will also help loosen congestion and keep you hydrated.

Where does all of this information leave us?

Zinc is potentially of great usefulness the treatment and prevention of the common cold. Use caution with dosing, however, to reduce side effects. Echinacea and vitamin C may or may not provide benefits, but don’t stop taking them if you feel they work for you. And, if you need another reason to exercise, reducing your cold’s duration may a good one. Lastly, for symptom relief, simple home remedies may work better than any supplements.

References:

(1) Open Respir Med J. 2011; 5: 51–58. (2) J Infect Dis. 2008 Mar 15;197(6):795-802. (3) ods.od.nih.gov. (4) Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. (5) Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000530. (6) Ann Intern Med. 2010;153(12):769-777. (7) British Journal of Sports Medicine 2011;45:987-992.

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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Build a risk-reduction arsenal with healthy food options

By David Dunaief, M.D.

Dr. David Dunaief

Happy “Movember!” In 2003, The Movember Foundation was founded in Australia to raise awareness and research money for men’s health issues (1). Its mission is to reduce the number of men dying prematurely 25 percent by 2030. From its modest beginnings with 30 participants, The Movember Foundation has expanded to 20 countries, more than six million participants, and funded over 1250 men’s health projects focused on mental health and suicide prevention, prostate cancer, and testicular canc

Movember Foundation’s prostate cancer initiatives focus on early detection, treatment options, and quality of life considerations for different treatments. Here, I’d like to add prevention options to the conversation.

The best way to avoid prostate cancer is with some simple lifestyle modifications. There are a host of things that may increase your risk and others that may decrease your likelihood of prostate cancer, regardless of family history.

What may increase the risk of prostate cancer? Contributing factors include obesity, animal fat and supplements, such as vitamin E and selenium. Equally as important, factors that may reduce risk include vegetables, especially cruciferous vegetables, and tomato sauce or cooked tomatoes.

Vitamin E and selenium – not the right choice

In the SELECT trial, a randomized clinical trial (RCT), a dose of 400 mg of vitamin E actually increased the risk of prostate cancer by 17 percent (2). Though significant, this is not a tremendous clinical effect. It does show that vitamin E should not be used for prevention of prostate cancer. Interestingly, in this study, selenium may have helped to reduce the mortality risk in the selenium plus vitamin E arm, but selenium trended toward a slight increased risk when taken alone. I would not recommend that men take selenium or vitamin E for prevention.

Manage your weight

Obesity showed conflicting results, prompting the study authors to analyze the results further. Ac-cording to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer, however increase risk of aggressive disease (3). The authors attribute the lower incidence of nonaggressive prostate cancer to the possibility that it is more difficult to detect the disease in obese men, since larger prostates make biopsies less effective. What the results tell us is that those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Lose or lower your animal fat and meat intake

There appears to be a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, a large observational study, those who consumed the highest amount of animal fat had a 63 percent increased risk, compared to those who consumed the least (4).

Here is the kicker: It was not just the percent increase that was important, but the fact that it was an increase in advanced or metastatic prostate cancer. Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you continue to eat red meat, reduce your frequency as much as possible, targeting once a month or quarter.

In another large, prospective observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (5).

I hope you love cooked tomatoes!

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown the same beneficial effects. It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit. Tomatoes need to be cooked to release lycopene (6). 

In a prospective study involving 47,365 men who were followed for 12 years, the risk of prostate cancer was reduced by 16 percent with higher lycopene intake from a variety of sources (7). When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 per-cent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

In the Health Professionals Follow-Up Study, the results were similar, with a 21 percent reduction in the risk of prostate cancer (8). Again, tomato sauce was the predominant food responsible for this effect. 

Although tomato sauce may be beneficial, many brands are loaded with salt, which creates its own bevy of health risks. I recommend to patients that they either make their own sauce or purchase prepared sauce made without salt.

Eat your (cruciferous) veggies

While results among studies vary, they all agree: consumption of vegetables, especially cruciferous vegetables, are beneficial to prostate cancer outcomes.

In a case-control study, participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (9). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

A separate study of 1338 patients with prostate cancer in a larger cancer screening trial concluded that, while vegetable and fruit consumption did not appear to lower outright prostate cancer risk, increased consumption of cruciferous vegetables – specifically broccoli and cauliflower – did reduce the risk of aggressive prostate cancer, particularly of more serious stage 3 and 4 tumors (10). These results were seen with consumption of just one or more servings of each per week, when com-pared to less than one per month.

When it comes to preventing prostate cancer, lifestyle modification, including making dietary changes, can reduce your risk significantly.

References:

(1) www.movember.com. (2) JAMA. 2011; 306: 1549-1556. (3) Epidemiol Rev. 2007;29:88. (4) J Natl Cancer Inst. 1993;85(19):1571. (5) Am J Epidemiol. 2009;170(9):1165. (6) Exp Biol Med (Maywood). 2002; 227:914-919. (7) J Natl Cancer Inst. 2002;94(5):391. (8) Exp Biol Med (Maywood). 2002; 227:852-859; Int. J. Cancer. 2007;121: 1571–1578. (9) J Natl Cancer Inst. 2000;92(1):61. (10) J Natl Cancer Inst. 2007;99(15):1200-1209.

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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Start with small, but key dietary changes

By David Dunaief

Dr. David Dunaief

Heart disease is an umbrella term that includes a number of disorders. Most common is coronary artery disease, which can cause heart attacks. Others include valve issues and heart failure, which is a problem with the pumping mechanism. We will focus on coronary artery disease and the resulting heart attacks.

According to the Centers for Disease Control and Prevention, about 6.7 percent of U.S. adults over the age of 19 have coronary artery disease (CAD) (1). There are 805,000 heart attacks in the U.S. annually, and 200,000 of these occur in those who’ve already had a first heart attack.

Among the biggest contributors to heart disease risk are high blood pressure, high cholesterol, and smoking. In addition, if you have diabetes or are overweight or obese, your risk increases significantly. Lifestyle choices also contribute to your risk: poor diet, lack of physical activity and high alcohol consumption are among the most significant contributors.

We can significantly reduce the occurrence of CAD. 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).

Can chocolate help?

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 high-cocoa-content dark chocolate daily. Aim for chocolate labeled with 80 percent cocoa content. Alternatively, you can get the benefits without the fat and sugar by adding unsweetened, non-Dutched cocoa powder to a fruit and vegetable smoothie.

Who says prevention has to be painful?

Increase your dietary fiber

Fiber has a dose-response relationship to reducing risk. In other words, the more fiber you eat, the greater your risk reduction. 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.

According to a 2021 analysis of National Health and Nutrition Examination Survey (NHANES) data from 2013 to 2018, only 5 percent of men and 9 percent of women get the recommended daily amount of fiber (4).

The average American consumes about 16 grams per day of fiber (5).

So, how much is “enough”? 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 (6).

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 fruits and vegetables with the edible skin or peel, beans and lentils, and whole grains.

Focus on legumes

 

Pixabay photo

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, legumes reduced the risk of coronary heart disease by a significant 22 percent (7). 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. 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 of legumes a day, or 7 to 14 a week. Imagine the impact that could have, compared to the modest four servings per week used to reach statistical significance in this study.

Add healthy nuts

In a study with over 45,000 men, there were significant reductions in CAD with omega-3 polyunsaturated fatty acids (PUFAs). Both plant-based and seafood-based omega-3s showed these effects (8). 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. Ideally, this requires a plant-based diet. But even modest changes in diet will result in significant risk reductions. The more significant the lifestyle changes you make, the closer you will come to achieving this goal.

References:

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) nutrition.org (5) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (6) eatright.org. (7) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (8) Circulation. 2005 Jan 18;111(2):157-164.

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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METRO photo
Annual eye exams are crucial

By David Dunaief, M.D.

Dr. David Dunaief

Diabetic retinopathy is a frequent consequence of diabetes and is the number one cause of blindness in the U.S. among those 20 to 74 years old (1). Diabetic retinopathy (DR) is an umbrella term for microvascular complications of diabetes that can lead to blurred vision and blindness.

Among the risk factors for DR are diabetes duration, glucose (sugar) that is not well-controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2). As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (3). Herein lies the challenge, because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.

Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by extracellular fluid accumulating in the macula (4). The macula is the region of the eye with greatest visual acuity. An oval spot in the central portion of the retina, it is sensitive to light. When fluid builds up from leaking blood vessels, there is potential for vision loss.

Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (3).

In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (5). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse damage. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes.

Treatment options

While DME has traditionally been treated with lasers, intravitreal (intraocular — within the eye) injections of anti-VEGF medications may be more effective. These work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (6).

The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab (Lucentis), whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).

Some diabetes drugs increase risk

You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (8). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings of other significant issues.

To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.

This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both of these studies were not without weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (10). Thus, there needs to be more study done to sort out these results.

Glucose control and diet

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But an inference can be made: A nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (12, 13).

The best way to avoid diabetic retinopathy and DME is obviously to prevent diabetes. Barring that, it’s to have sugars well-controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones.

References:

(1) cdc.gov. (2) JAMA. 2010;304:649-656. (3) www.aao.org/ppp. (4) www.uptodate.com. (5) JAMA Ophthalmol. 2014;132:168-173. (6) Community Eye Health. 2014; 27(87): 44–46. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.

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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