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Even modest exercise may impact your health outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote about the challenges of relying on exercise for weight loss. That’s not to say that it’s not important to exercise. It has powerful effects in altering how our genes express themselves and can improve our outcomes with specific diseases, such as diabetes and a host of other health issues, including kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Despite all the positives, it’s sometime difficult to motivate yourself to exercise. However, there are some simple ways to motivate yourself during exercise. One study showed that those who repeated positive mantras to themselves during exercise were able to persist for longer periods (2).

Why is this so important now? Because we are too sedentary, and this is the time of the year when we are especially so. According to data from the 2015-2018 Behavioral Risk Factor Surveillance System, the Northeast had among the highest levels of physical inactivity by U.S. region, at 25.6 percent of the population (3).

Can exercise alter your fat genes?

Exercise may have a significant impact on how our genes express themselves.

In a study, results showed that thousands upon thousands of genes in fat cells were affected when participants exercised for six months (4). The study involved sedentary men and had them exercise twice a week at a one-hour spin class. According to the researchers, the genes impacted were those involved most likely in storing fat and in risk for subsequent diabetes and obesity development. These participants also improved other important health metrics, including their cholesterol, blood-pressure, fat percent and, later, their waist circumferences.

The effect identified on the fat cells is referred to as epigenetics, where lifestyle modifications ultimately lead to changes in gene expression, turning them on and off. This has been shown with dietary changes, but this is one of the first studies to show that exercise also has significant impacts on our genes. It took only six months to see these numerous gene changes with modest amounts of cardiovascular exercise.

Do you need more encouragement? Another study showed substantial gene changes in muscle cells after one workout on a stationary bike (5). Yet another introduced six weeks of endurance exercise to healthy, but sedentary, young men and identified an abundance of genetic changes to skeletal muscle with broad impacts on physical and cognitive health (6).

Which is better: exercise or drug therapy?

What if we could forgo medications for cardiovascular disease by exercising? One meta-analysis, which examined 57 studies that involved drugs and exercise, showed similar benefits between statins and exercise in mortality with secondary prevention of coronary heart disease (7). This means that, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same study also showed benefits for those with pre-diabetes and the use of metformin vs. exercise. It didn’t matter which one was used, the drug or the lifestyle change.

While these results are exciting, don’t change your medication without consulting your physician.

How does exercise help with kidney stones?

Anyone who has tried to pass a kidney stone knows it can be an excruciating experience. Most of the treatment involves pain medication, fluids and waiting for the stone to pass. However, the best way to treat kidney stones is to prevent them.

In the Women’s Health Initiative Observational Study, exercise reduced the risk of kidney stones by as much as 31 percent (8). Even better, the intensity of the exercise did not change its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results; however, lesser amounts of exercise also saw substantial reductions. This study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones.

Is sexual activity really exercise?

We have heard that sex may be thought of as exercise, but is this myth or is there actual evidence? According to research, this may be true. In a study, researchers found that young, healthy couples exert 6 METs — metabolic energy, or the amount of oxygen consumed per kilogram per minute — during sexual activity (9).

How does this compare to other activities? We exert about 1 MET while sitting and 8.5 METs while jogging. In terms of energy utilized, sexual activity falls between walking and jogging, therefore, it can be qualified as moderate activity. Men and women burned almost half as many calories with sex as with jogging, burning a mean of 85 calories over about 25 minutes. Who says exercise isn’t fun?

I can’t stress the importance of exercise enough. It not only helps you feel better, it may also influence gene expression and, ultimately, affect your development and prevention of disease. In certain circumstances, it may be as powerful as medications. Therefore, make exercise a priority — part of the fabric of your life. It may already be impacting the fabric of your body: your genes.

References:

(1) JAMA. 2009;301(19):2024. (2) Med Sci Sports Exerc. 2013 Oct 10. (3) cdc.gov. (4) PLoS Genet. 2013 Jun;9(6):e1003572. (5) Cell Metab. 2012 Mar 7;15(3):405-11. (6) Mol Metab. 2021 Nov;53:101290. (7) BMJ. 2013; 347. (8) JASN. 2013;24(3):p 487-497. (9) PLoS One 8(10): e79342.

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

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Exercise is only one part of the weight loss equation

By David Dunaief, M.D.

Dr. David Dunaief

Exercise has benefits for a wide range of medical conditions, from insomnia, fatigue, depression and cognitive decline to chronic kidney disease, diabetes, cardiovascular disease and osteoporosis. But will it help you lose weight? 

While exercise equipment and gym membership ads emphasize this in January, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance.

Ultimately, it may be more important to reconsider what you are eating than to succumb to the rationalization that you can eat with abandon and work it off later.

Does exercise help with weight loss?

The well-known weight-loss paradigm is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise. This is a moderately intense pace.

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Does exercise help with weight maintenance?

Exercise may help with weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Does exercise help with disease?

As a simple example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects approximately 15 percent of U.S. adults, according to the Centers for Disease Control and Prevention (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3-5 (8). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact, and results were based on a dose-response curve. In other words, the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

As you can see, there are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

By all means, exercise, but to lose weight, also focus on consuming nutrient-dense foods instead of calorie-dense foods that you may not be able to exercise away.

References:

(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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

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A poor diet can increase your risk for high blood pressure. METRO photo
Medication timing has a significant effect on cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

We are at the point in the year when many of us are taking stock of how we’ve fared over our last trip around the sun. 

If you are one of the 47 percent of U.S. adults over the age of 18 with hypertension, also known as high blood pressure, you don’t want to be one of the 92 million whose hypertension is uncontrolled (1). When it’s not controlled, you increase your probability of complications, such as cardiovascular events and mortality.

What contributes to our risk of hypertension complications?

Being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol are some of the factors that increase our risk (2). The good news is that you can take active steps to improve your risk profile (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits.

Which risk factors have the greatest impact on developing hypertension?

A poor diet can increase your risk for high blood pressure. METRO photo

In an observational study involving 2,763 participants, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (4). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²), which put participants at 1.87 times increased risk. This, surprisingly, trumped cigarette smoking, which increased risk by 1.83 times. 

What effect does your gender, age or race have?

While the data show that more men than women have hypertension, 50 percent vs. 44 percent, and the prevalence of high blood pressure varies by race, the consequences of hypertension are felt across the spectrum of age, gender and race (5).

One of the most feared complications of hypertension is cardiovascular disease. In a study, isolated systolic (top number) hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (6). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. 

High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, it was very large and had a 31-year duration.

Are nighttime blood pressure readings better risk predictors?

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (6).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration.

Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (7). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

A previous study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Do blueberries help control blood pressure?

Diet plays a role in controlling high blood pressure. In a study, 22 grams of blueberry powder consumed daily, equivalent to one cup of fresh blueberries, reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (9).

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase nitric oxide, which helps blood vessels relax, reducing blood pressure. While the study used powder, it’s possible that an equivalent amount of real fruit would lead to greater reduction.

In conclusion, high blood pressure and its cardiovascular complications can be scary, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References:

(1) millionhearts.hhs.gov. (2) uptodate.com. (3) Diabetes Care 2011;34 Suppl 2:S308-312. (4) BMC Fam Pract 2015;16(26). (5) cdc.gov. (6) J Am Coll Cardiol 2015;65(4):327-335. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377.

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

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In order to be aware of potentially adverse events, you have to be your own best advocate and read labels. METRO photo
Recently updated FDA warnings highlight risks

By David Dunaief, M.D.

Dr. David Dunaief

What’s in your medicine cabinet?

Many of us keep a supply of over-the-counter medications for pain relief, fever and inflammation. This could include acetaminophen and a variety of NSDAIDs, such as aspirin, ibuprofen, naproxen sodium and diclofenac sodium.

“NSAIDs” is shorthand for non-steroidal anti-inflammatory drugs, which are available by prescription or over-the-counter (OTC) at your local pharmacy or at any newsstand. Familiar NSAID brand names include Advil, Motrin, Aleve and Voltaren.

Americans consume more than 30 billion doses of NSAIDs a year, including both prescription and OTC use (1). As for acetaminophen, also known by the brand name, Tylenol, one quarter of Americans take it weekly. 

Perhaps because they’re so easy to access and take, many think of these drugs as low risk. According to a poll of regular OTC NSAID users, 60 percent of them were not aware that they can have dangerous side effects (2).

They are so commonplace that most of my patients don’t even include them in a list of medications they take. I need to specifically ask about them.

Why be concerned about NSAIDs?

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). 

NSAIDs increase the risk of several maladies, including heart attacks, gastrointestinal bleeding, stroke, 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 in 2015, 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).

As recently as late 2020, the FDA added a warning label to non-aspirin NSAIDs about the potential for fetal kidney damage and pregnancy complications beginning around week 20 of a pregnancy (4).

Research on NSAID complications

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. 

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 than NSAIDs?

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.

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 any OTC medications.

If you are a chronic user of NSAIDs or acetaminophen because of underlying inflammation, you may find an anti-inflammatory diet 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 or consult your personal physician.

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By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

It’s been a while since I wrote, and I know you have a lot of last-minute requests at this time of year, so I’ll keep this short.

Kids around the world look to you as a role model for kindness and generosity. That must feel pretty good.

They also marvel at your round belly, claiming that it shakes when you laugh like a bowl full of jelly. Then, they literally feed that belly by setting out cookies and other sweets for you on Christmas Eve.

I have nothing against your round belly, but I’m concerned about the message it sends. We’re currently facing an epidemic of overweight kids and an ever-increasing number of children with type 2 diabetes. According to the CDC, the percentage of children in the U.S. between ages 10 and 19 with type 2 diabetes nearly doubled from 2001 to 2017. You, Santa, with your influence, can help reverse this trend.

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

Santa, here is your opportunity 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 personal advantages of being trimmer. Your joints won’t ache with the winter cold, and you will have more energy. Plus, studies show that, with a diet that emphasizes fruits, vegetables and whole grains, you can reverse clogged arteries and avoid strokes, heart attacks and peripheral vascular disease. With a simple change, like eating a handful of raw nuts a day, you can reduce your heart disease risk significantly.

Losing weight will also change your center of gravity, which will make it easier for you to keep your balance on those steep, icy rooftops.

Exercise will help as well. Maybe this Christmas Eve, you could walk or jog alongside the sleigh for the first continent or so. As you continue to exercise during the “offseason,” you’ll start to tighten your abs and slowly see fat disappear from your midsection.

This might make it easier to steal a base or two during the North Pole Athletic League’s Softball season. The elves don’t even bother holding you on base anymore, do they?

Of course, the cookies don’t help. 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. And, of course, skip putting candy in the stockings. No one needs more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a few pieces, yourself.

As for your loyal fans, you could place active games under the tree. You and your elves could create an app with 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 the next Shaun T!

You could gift athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games. Or wearable devices that track step counts and bike routes. Or stuff gift certificates for dance lessons into people’s stockings.

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 be able to park the sleigh farther away and skip from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Your reindeer won’t have to work so hard. You might 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 coming year,

David

P.S. If you have a little extra room in your sleigh, I could use a new pair of batting gloves. I hear the Yankees need help, and I’ve been practicing, just in case.

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 improves bone health and brain volume

By David Dunaief, M.D.

Dr. David Dunaief

What does it take to get Americans off the sofa? We know that exercise is good for our long-term physical and mental health, but it’s still elusive for the majority of us. It’s just too tempting to let the next episode of our new favorite series autoplay or to answer those last 12 emails.

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.” I once heard that the couch is as bad as the worst deep-fried food. It perpetuates inactivity. Even sleeping burns more calories than sitting watching TV, for example.

I think part of the problem might be that we don’t know what type of exercise is best and how long and frequently to do it. 

I have good news. 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.

Participants who had an increase in brain tissue volume also 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 it’s 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. Sadly, 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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By David Dunaief, M.D.

Dr. David Dunaief

Heart disease gets a lot of attention, because it’s still the number one cause of death in the U.S. We know that diet plays a significant role in this, but so do our genes.

What if we could tackle genetic issues with diet? 

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.

The role of genes

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 aligns with what we see in 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, such as with 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 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 opposing 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.

So, what have we learned? Even with a genetic proclivity toward cardiovascular disease, we can alter our cardiovascular destinies.

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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While they can be scary, most thyroid nodules are benign

By David Dunaief, M.D.

Dr. David Dunaief

Thyroid nodules are diagnosed, 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 because of symptoms (1). More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound (2). Fortunately, most are benign. A small percent are malignant. Depending on the study, this can range from 1.1 to 6.5 percent of nodules (3, 4). 

There is a conundrum of what to do with a thyroid nodule. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (5). 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 (6).

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 (7). 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. Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam (8).

Evaluating indeterminate FNA 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 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 it did not do a good job of identifying those who did have cancer (9).

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (10).

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

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 (11). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk.

Considering a “wait and follow-up” approach

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 (12). 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’s role

In considering risk factors, it’s 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 (13).

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

References: 

(1) uptodate.com. (2) AACE 2013 Abstract 1048. (3) Thyroid. 2005;15(7):708. (4) European Thyroid Journal. 2022 Jun 29;11(4) online. (5) AACE 2013 Abstract 1048. (6) thyroid.org. (7) AAES 2013 Annual Meeting. Abstract 36. (8) AACE 2013 Abstract 1048. (9) Cancer. 2011;117(20):4582-4594. (10) J Clin Endocrinol Metab. Online May 12, 2015. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) 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 headaches and fatigue are common consequences

By David Dunaief, M.D.

Dr. David Dunaief

During the summer, we talk a lot about the dangers of dehydration. However, it can also cause problems during the cooler winter months. Dry heat quickly evaporates moisture in the air, making it hard to stay hydrated or to keep any humidity in your home or office. This can dehydrate us.

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.

Let’s look at some of the consequences of dehydration and suggestions for keeping hydration up.

Headaches and 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 contributing to this (2). They occur mainly when we don’t hydrate prior to exercise. If you drink one glass of water before exercise and then drink during exercise, it will help avoid palpitations. Though these symptoms are not usually life-threatening, they can make you anxious.

Heart attacks

The Adventist Health Study showed that men who drank more water had the least risk of death from heart disease (3). Group one, which drank more than five glasses of water daily, had less risk than group two, which drank more than three. Those in group three, which drank fewer than two glasses per day, saw the lowest 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 and fatigue

Mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women in a small study (4). 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.

How much water?

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 the magic number (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) diets, have a plant-rich focus. Diets with a focus on fruits and vegetables increase 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 dehydrate you, including breads and pastries, so try to avoid these.

Caffeinated beverages

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 heated air can promote, 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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It’s time to change up your holiday dinner options

By David Dunaief, M.D.

Dr. David Dunaief

Many consider Thanksgiving a time to indulge and not think about the repercussions. Even if we have the best of intentions, it’s hard to resist indulging in our childhood favorites and secret family recipes spread before us in a sprawling buffet.

Unfortunately, that one meal, and perhaps subsequent leftover meals, can have striking health consequences. And if you tend to overeat, be aware that 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 (1). If you can fend off weight gain during the holidays, think of the possibilities for the rest of the year.

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 (2). 

The good news is that, with a little Thanksgiving planning, you can reap significant health benefits.

What can we do to turn Thanksgiving dinner into a healthy meal? The secret is likely there on your table, hidden in the side dishes. By reconsidering how we prepare them, we can change the Thanksgiving health equation.

Refocus on plants

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 (3).

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.

Focus on healthy 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 and butter, negating their benefits, but clearing our consciences. Fruits are buttered and sugared beyond recognition or used as a garnish on more decadent dishes.

Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. 

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 sauté it in a splash of citrus-infused balsamic vinegar and add sliced apples. 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 choices. Why would you serve vegetables without any seasoning? In my family, we season vegetables and make sauces to drizzle over them. Personally, I’m a fan of infused vinegars. Each adds a different flavor to the vegetables. 

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 last 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 (4). 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: https://medicalcompassmd.com/post/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) N Engl J Med 2000; 342:861-867. (2) www.heart.org. (3) Crit Rev Food Sci Nutr 2010;50(8):728–760. (4) 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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