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Exercise can actually reduce a cold’s duration

By David Dunaief, M.D,

Dr. David Dunaief

With autumn upon us, cold season is sneaking up on us. Most frequently caused by the notorious human rhinovirus, a cold’s effects can range from an annoyance to more serious symptoms that put us out of commission for a week or more.

The good news is that it may be possible to reduce the symptoms — or even reduce the duration — of a common cold with supplements and lifestyle management.

Here, we’ll separate myth from fact about which supplements may be beneficial and which may not. 

How can you get symptom relief?

Let’s start with the basics to meet your most immediate need when you start experiencing cold symptoms.

If you have congestion or coughing symptoms, time-tested symptom relief may help. Sitting in a steamy bathroom, which simulates a medical mist tent, can help. Remember, 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.

Does zinc really help?

You may have heard that zinc helps 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 your symptoms throughout, improving your quality of life. This may be due to an anti-inflammatory effect.

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). 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. First, the dose researchers used was well above the maximum intake recommended by the National Institutes of Health, which is 40 mg per day for adults. This maximum intake number is less for those 18 and younger (3). Also, note that the FDA has warned against nasal zinc administration with sprays, which has led to permanent loss of smell for some people.

As for the studies, not all studies showed a benefit. Also, 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.

What about 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 or reduction of cold 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.

Is echinacea a magic bullet?

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 showing 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).

Should you 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 the number of days with colds compared to those who perceived themselves to have low fitness. The symptoms of colds were reduced significantly as well.

What’s the upshot?

For symptom relief, simple home remedies may work better than any supplements. Zinc is potentially useful in treating and preventing 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 help you. Lastly, exercise can actually reduce your cold’s duration.

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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New research on PSA outcomes can inform your screening decisions

By David Dunaief, M.D.

Dr. David Dunaief

You may see more fuzzy faces among men this month. Welcome to “Movember,” when men grow facial hair to raise awareness and research money for men’s health issues (1). An initiative of the Movember Foundation, the intention is to fund men’s health projects focused on mental health and suicide prevention, prostate cancer, and testicular cancer.

Its prostate cancer initiatives focus on early detection, treatment options, and quality of life considerations for different treatments. Here, I’ll add prevention options to the conversation.

Regardless of your family history, you can reduce your risk of prostate cancer with simple lifestyle modifications. Factors that contribute to increased risk include obesity, animal fat, and supplements. Equally as important, factors that reduce risk include vegetables, especially cruciferous vegetables, and tomato sauce or cooked tomatoes.

I’ll also share new research to inform your decision-making about prostate-specific antigen (PSA) screening.

Obesity’s effect

According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer; however, it may also increase your risk of aggressive disease (2). Because larger prostates make biopsies less effective, the authors attribute the lower incidence of nonaggressive cancer to the possibility that it is more difficult to detect it in obese men. Ultimately, those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Animal fat

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, those who consumed the highest amount of animal fat had a 63 percent increased risk of in advanced or metastatic prostate cancer, compared to those who consumed the least (3).

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 (4).

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 (5). 

As part of this larger study, 32 patients with localized prostate cancer consumed 30 mg of lycopene per day via tomato sauce-based dishes over a three-week period before radical prostatectomy. Key cancer indicators improved, and tissue tested before and after the intervention showed dramatic improvements in DNA damage in leukocyte and prostate tissue (6). 

In a prospective study involving 47,365 men who were followed for 12 years, prostate cancer risk 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 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

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.

Cruciferous vegetables

While results among studies vary, they all agree: consumption of vegetables, especially cruciferous vegetables, help reduce prostate cancer risk.

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 (8). 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 (9). These results were seen with consumption of just one or more servings of each per week, when compared to less than one per month.

What about PSA screening?

In a recently published retrospective analysis of 128 Veteran’s Administration facilities, those where PSA screening was less frequent found higher rates of metastatic prostate cancer (10). During the study period from 2005 to 2019, researchers found an inverse relationship between PSA screening rates and metastatic prostate cancer. When screening rates decreased, rates of metastatic cancer increased five years later, while in facilities where screening rates increased, metastatic cancer rates decreased. While the study authors caution about extending these findings to the general population, they do suggest they could help inform conversations between men and their physicians about the value of PSA screening. 

When it comes to preventing prostate cancer and improving prostate cancer outcomes, lifestyle modifications, including making dietary changes, can reduce your risk significantly.

References: 

(1) www.movember.com. (2) Epidemiol Rev. 2007;29:88. (3) J Natl Cancer Inst. 1993;85(19):1571. (4) Am J Epidemiol. 2009;170(9):1165. (5) Exp Biol Med (Maywood). 2002; 227:914-919. (6) J Natl Cancer Inst. 2002;94(5):391. (7) Exp Biol Med (Maywood). 2002 Nov;227(10):886-93. (8) J Natl Cancer Inst. 2000;92(1):61. (9) J Natl Cancer Inst. 2007;99(15):1200-1209. (10) JAMA Oncol. Published online October 24, 2022.

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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Legume consumption plays an important role

By David Dunaief, M.D.

Dr. David Dunaief

Coronary artery disease is the most common type of heart disease, which can cause heart attacks. How common is it? 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 factors also contribute to your risk: poor diet, lack of physical activity and high alcohol consumption are among the most significant contributors.

This is where we can have a tremendous impact and significantly reduce the occurrence of CAD. Evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Changes that garner a big bang for your buck include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Chocolate’s benefits

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 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.

Consume more legumes

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 saw this effect when compared to those who consumed less than one serving per week. The legumes used in this study included beans, peas and peanuts. There were over 9,500 men and women involved, and the study spanned 19 years of follow-up.

I recommend that patients consume at least one to two servings a day, or 7 to 14 a week. Imagine the impact that could have, compared to the modest four servings per week used to reach statistical significance in this study.

Focus on 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. While even modest dietary changes can significantly reduce your risk, 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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Sugar control and regular eye exams are your best defense

By David Dunaief, M.D.

Dr. David Dunaief

We talk a lot in the medical community about the vascular consequences of diabetes, and rightly so. If you have diabetes, you are at high risk of vascular complications that can be life-altering. Among these are macrovascular complications, like coronary artery disease and stroke, and microvascular effects, such as diabetic nephropathy and retinopathy.

Here, we will discuss diabetic retinopathy (DR), the number one cause of blindness among U.S. adults, ages 20 to 74 years old (1). Diabetic retinopathy (DR) is when the blood vessels that feed the light-sensitive tissue at the back of your eye are damaged, and it can progress to blurred vision and blindness.

As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (2). Why does this matter? 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 fluid accumulating in the macula (3). An oval spot in the central portion of the retina, the macula is sensitive to light. When fluid builds up from leaking blood vessels, it can cause 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 (2).

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 (4). 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.

Unfortunately, the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse the damage.

Treatment options

While DME has traditionally been treated with lasers, injections of anti-VEGF medications may be more effective. These eye injections work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (5).

The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were equally effective in treating DME (6). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).

Risk from diabetes treatments

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 (7). 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 for 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 (8). 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 studies had 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 (9). There are additional studies underway to clarify 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 (10). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, 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 (11, 12).

If you have diabetes, the best way to avoid diabetic retinopathy and DME is to maintain good control of your sugars. Also, it is imperative that you have a yearly eye exam by an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.

References: 

(1) cdc.gov. (2) www.aao.org/ppp. (3) www.uptodate.com. (4) JAMA Ophthalmol. 2014;132:168-173. (5) Community Eye Health. 2014; 27(87): 44–46. (6) ASRS. Presented 2014 Aug. 11. (7) Arch Intern Med. 2012;172:1005-1011. (8) Arch Ophthalmol. 2010 March;128:312-318. (9) Arch Intern Med. 2012;172:1011-1013. (10) www.nei.nih.gov. (11) OJPM. 2012;2:364-371. (12) 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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Cut down on late night snacking to avoid GERD. METRO photo
Increased fiber and exercise improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

After a large meal, many people suffer from occasional heartburn and regurgitation, where stomach contents flow backward up the esophagus. This reflux happens when the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Many incidences of reflux are physiologic (normal functioning), especially after a meal, and doesn’t require medical treatment (1).

Gastroesophageal reflux disease (GERD), on the other hand, is long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). This is one reason pharmaceutical firms give it so much attention, lining our drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers can also play a role. They can include spicy, salty, or fried foods, peppermint, and chocolate.

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Let’s examine available treatments and ways to reduce your risk.

Evaluate medication options

The most common and effective medications for treating GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use include increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Understand PPI risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (9). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician. Before stopping PPIs, consult your physician. Rebound hyperacidity (high acid produced) can result from stopping them abruptly.

Increase fiber and exercise

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the study that quantified the risks of smoking and salt, fiber and exercise both had the opposite effect, reducing GERD risk (5). An analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (11).

Manage weight

In one study that examined obesity’s role in GERD exacerbation, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index.

Avoid late night eating

One of the most powerful modifications we can make to avoid GERD is among the simplest. A study showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.” While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References: 

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar; 130:639-649. (13) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

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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The American Cancer Society recommends women 45-54 get annual screenings. METRO photo
New research on bisphosphonates helps clarify their role in prevention

By David Dunaief, M.D.

Dr. David Dunaief

Breast cancer is the most common cancer diagnosed in U.S. women. Experts estimate that 30 percent of 2022 cancer diagnoses in women will be breast cancer (1). Only 15 percent of cases occur in those who have a family history of the disease, and 85 percent of new diagnoses will be invasive breast cancer.

A primary objective of raising awareness during October is to promote screening for early detection. Screening is crucial, but it is not prevention, which is just as important. Prevention strategies should include primary prevention, preventing the disease from occurring by lowering your risk, and secondary prevention, preventing breast cancer recurrence.

Here, we will discuss current screening recommendations, along with tools to lower your risk.

What are current screening recommendations?

There is some variation in screening guidelines; experts don’t agree on age and frequency. The U.S. Preventive Services Task Force currently recommends mammograms every other year, from age 50 through age 74, with the option of beginning as early as age 40 for those with significant risk (2). These 2016 guidelines are currently undergoing a review and are pending publication.

The American College of Obstetricians and Gynecologists encourages a process of shared decision-making between patient and physician to determine age and frequency of exams, including whether to begin exams before age 50 or to continue after age 75 (3). Generally, it recommends beginning annual or biennial mammograms starting no later than 50 and continuing until age 75. 

The American Cancer Society’s physician guidelines are to offer a mammogram beginning at age 40 and recommend annual exams from 45 to 54, with biennial exams after 55 until life expectancy is less than 10 years (4).

It is important to consult with your physician to identify your risk profile and plan or revise your regular screening schedule accordingly.

When do bisphosphonates help?

Bisphosphonates, which include Fosamax (alendronate), Zometa (zoledronic acid) and Boniva (ibandronate), are used to treat osteoporosis. Do they have a role in breast cancer risk prevention? The short answer: it may help prevent recurrence but doesn’t appear to provide primary protective benefits.

In a meta-analysis involving two randomized controlled trials (RCTs), FIT and HORIZON-PFT, results showed no benefit from the use of bisphosphonates in reducing breast cancer risk (5). The study population involved 14,000 postmenopausal women from ages 55 to 89 women who had osteoporosis, but who did not have a personal history of breast cancer. In other words, bisphosphonates were being used for primary prevention.

However, it does appear that bisphosphonates have a role in preventing breast cancer recurrence. The recent SUCCESS A phase 3 trial considered the optimal time for treatment. Findings published in 2021 indicate that two years of treatment for patients with high-risk early breast cancer reduced recurrence risk as much as five years of treatment (6). This could alter the current paradigm of 3-to-five years of treatment to prevent recurrence of certain types of breast cancer, reducing incidences of troublesome side effects.

A Lancet metanalysis focused on breast cancer recurrence in distant locations, including bone, and survival outcomes did find benefits for postmenopausal women (7). A good synopsis of the research can be found at cancer.org.

What’s the role of exercise?

We know exercise is important in diseases and breast cancer is no exception. In an observational trial, exercise reduced breast cancer risk in postmenopausal women significantly (8). These women exercised moderately; they walked four hours a week over a four-year period. If they exercised previously, five to nine years ago, but not recently, no benefit was seen. The researchers stressed that it is never too late to begin exercise. Only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. We need to expend as much energy and resources emphasizing exercise for prevention as we do screenings.

What about soy?

Contrary to popular belief, soy may be beneficial in reducing breast cancer risk. In a meta-analysis, those who consumed more soy saw a significant reduction in breast cancer compared to those who consumed less (9). There was a dose-response curve among three groups: high intake of >20 mg per day, moderate intake of 10 mg and low intake of <5 mg. Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk when compared to those who consumed the least. In addition, higher soy intake has been associated with reduced recurrence and increased survival for those previously diagnosed with breast cancer (10). The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

Hooray for Breast Cancer Awareness Month stressing the importance of mammography and breast self-exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a Mediterranean diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence.

References: 

(1) breastcancer.org. (2) uspreventiveservicestaskforce.org. (3) acog.org. (4) cancer.org. (5) JAMA Intern Med. 2014;174(10):1550-1557. (6) JAMA Oncol. 2021;7(8):1149–1157. (7) Lancet. 2015 Jul 23. (8) Cancer Epidemiol Biomarkers Prev. 2014 Sep;23(9):1893-902. (9) Br J Cancer. 2008; 98:9-14. (10) JAMA. 2009 Dec 9; 302(22): 2437–2443.

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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Eczema is more common in women than it is in men. METRO photo
Treatments are continually evolving

By David Dunaief, M.D.

Dr. David Dunaief

The causes of eczema are unknown, but it is thought that nature and nurture are both at play (1). Essentially, it is a chronic inflammatory process that involves symptoms of rashes, itching, pain and redness (2).

It’s estimated that over seven percent of the U.S. adult population suffers from eczema (3), with twice as many females as males affected (4).

While there is no cure, there are treatments its symptoms. These range from over-the-counter creams and lotions to prescription steroid creams to oral steroids and injectable biologics. Antihistamines can also be used to treat itchiness. Some use phototherapy for severe cases, but research on its effectiveness is scant. Interestingly, lifestyle, specifically diet, may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

Let’s look at the evidence.

Does diet play a role?

Eczema is more common in women than it is in men. METRO photo

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (5).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (6).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15 to 20 percent of patients who suffer some level of eczema. For example, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin significantly improved.

What about supplements?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective – and with some important concerns.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (7). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (8).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Biologics

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (9). There are two currently approved by the FDA, dupilumab and tralokinumab-ldrm, with the latter recently approved in December 2021.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like any drug therapy, it does have side effects.

Deeper impacts of eczema

Eczema may be related to broken bones, according to several studies. For example, one observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more disturbing 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (10).

And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that the use of corticosteroids in treatment could be one reason for increased fracture risk, in addition to chronic inflammation, which may also contribute to the risk of bone loss.

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A recently published study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (11). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (12). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroid use, because of the long-term side effects. Lifestyle modifications appear to be very effective, at least at the anecdotal level.

References: 

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) uptodate.com. (3) J Inv Dermatol. 2017;137(1):26-30. (4) BMC Dermatol. 2013;13(14). (5) Allergy. 2010 Jun 1;65(6):758-765. (6) J Am Acad Dermatol. 2004;50(3):391-404. (7) Cochrane Database Syst Rev. 2013;4:CD004416. (8) mayoclinic.org (9) Medscape.com. (9) JAMA Dermatol. 2015;151(1):33-41. (10) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (11) nationaleczema.org. (12) Contact Dermatitis 2008; 59:43-47.

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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5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular and all-cause mortality. METRO photo
Modest lifestyle changes can add quality years

By David Dunaief, M.D.

Dr. David Dunaief

This past Monday, Canada honored the life of Queen Elizabeth II. Among other tributes, there was a 96-shot salute, with one shot for each year of her life. As you might imagine, it took a while.

While living to 96 was once unusual, it’s becoming more common. According to the National Institutes of Health, those in the U.S. who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those aged 85 and older.

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

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

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

Get at least modest exercise

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

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

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

A study presented this past August at the European Society of Cardiology Congress looked at the role of simple physical activity in the elderly (6). It found that those 85 and older reduced the risk of all-cause mortality 40 percent by walking just 60 minutes a week. This is physical activity that does not actually qualify as exercise.

Eat less animal protein

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

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

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

The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein once a week or less had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (8). This was an observational trial with over 73,000 participants and a median age of 57 years old.

Reduce systemic inflammation

In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ longevity (9). In fact, if participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.

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

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

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

References: 

(1) nia.nih.gov. (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) J Am Coll Cardiol. 2014;64:472-481. (5) J Am Coll Cardiol. 2014;64:482-484. (6) European Society of Cardiology Congress, Aug. 28, 2022. (7) Cell Metab. 2014;19:407-417. (8) JAMA Intern Med. 2013;173:1230-1238. (9) CMAJ. 2013;185:E763-E770.

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

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Diabetes. METRO Photo
In some patients, small amounts of wine may reduce cardiovascular risks

By David Dunaief, M.D.

Dr. David Dunaief

Our understanding of diabetes — its risks and treatment paradigms — is continually evolving and improving. This is good news, since the current rate of diabetes among the U.S. adult population is 13 percent, while another estimated 88 million U.S. adults have prediabetes (1).

What is prediabetes? Typically, it’s when fasting glucose levels (HbA1C) sit in the 5.7 and 6.4 percent range.

With diabetes comes a host of other health complications, including increased heart attack risk. However, cardiovascular risk and its severity may not equally affect men and women. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a higher rate than men, although both had substantial risk increases, 162 percent and 96 percent, respectively (2).

What might reduce our risks for diabetes or its complications? Fortunately, we have options. These include diet improvements, timing of blood pressure medications, and, oddly, modest wine consumption.

Diet bests metformin for diabetes prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is a disservice; lifestyle changes may be more effective in preventing this disease.

In a head-to-head comparison study, diet plus exercise outperformed metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: one received a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; one took metformin 875 mg twice a day; and one was a placebo group. Diet and exercise reduced diabetes risk by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, the diet they used was not an optimal diabetes diet.

Blood pressure medications’ timing

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (4). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of diabetes risk than morning blood pressure or 48-hour ambulatory blood pressure. This study had a long duration of almost six years with about 2,000 participants.

Researchers used three blood pressure medications in the trial: ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers.

The first two have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, these had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes.

Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.

Can wine help?

Diabetes patients are often warned to limit or eliminate alcohol. A significant part of the reasoning relates to how the body metabolizes alcohol and sugars. So, the results of a study that showed small amounts of wine could have benefits in reducing diabetes-associated complications among those whose sugars were well-controlled sent ripples throughout the medical community.

The CASCADE trial, a randomized controlled trial, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (5).

Patients were randomized into three groups, each receiving a drink with dinner nightly. One group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily. This was a small study, and participants were well-controlled type 2 diabetes patients who generally were nondrinkers.

We need to reverse the trend toward higher diabetes prevalence. The good news is that we’re continuing to learn what lowers diabetes risk and, for those with Type 2 diabetes, what can improve cardiovascular risks.

References: 

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Diabetologia. Online Sept. 23, 2015. (5) Ann Intern Med. 2015;163(8):569-579.

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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Stock photo
Antioxidant diet may improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. Unlike a heart attack, which is acute, heart failure develops slowly and may take years to become symptomatic.

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

We have more medical research on systolic heart failure. Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue.

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

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

Increasing antioxidants in the diet

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

In a population-based, prospective study, the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (1). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

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

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

Addressing iron deficiencies

An observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (2).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L. The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients.

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

References: 

(1) Am J Med. 2013 Jun:126(6):494-500. (2) Am Heart J. 2013;165(4):575-582.

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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