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plant-based diet

Try eating a more plant-based, whole foods diet. METRO photo
Cardiac biomarkers can help you monitor your progress

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is on the decline in the U.S. Several factors have influenced this, including better awareness, improved medicines, earlier treatment of risk factors and lifestyle modifications (1). Still, we can do better. Heart disease still underpins one in four deaths, and it is preventable.

What are the baseline risks for heart disease?

Significant risk factors for heart disease include high cholesterol, high blood pressure and smoking. In addition, diabetes, excess weight and excessive alcohol intake increase your risks. Unfortunately, both obesity and diabetes rates are increasing. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2).

Inactivity and the standard American diet, which is rich in saturated fat and calories, also contribute to atherosclerosis, or fatty streaks in the arteries, the underlying culprit in heart disease risk (3).

A less-discussed risk factor is a resting heart rate greater than 80 beats per minute (bpm). A normal resting heart rate is typically between 60 and 100 bpm. If your resting heart rate is in the high-normal range, your risk increases.

In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (4). The good news is that you can reduce your risks.

Does medication lower heart disease risk?

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. Unfortunately, according to 2018 National Health and Nutrition Examination Survey (NHANES) data, only 43.7 percent of those with hypertension have it controlled (5). While the projected reasons are complex, a significant issue among those with diagnosed hypertension is their failure to consistently take their prescribed medications.

Statins have played a key role in primary prevention, as well. They lower lipid levels, including total cholesterol and LDL (“bad” cholesterol). They also lower inflammation levels that contribute to cardiovascular disease risk. The JUPITER trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

The downside of statins is their side effects. Statins have been shown to increase the risk of diabetes in intensive dosing, when compared to moderate dosing (6).

Unfortunately, another side effect of statins is myopathy (muscle pain). I have a number of patients who suffered from statin muscle pain and cramps shift their focus to diet and exercise to get off their prescriptions. Lifestyle modification is a powerful ally.

Do lifestyle changes really reduce heart disease risk?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required modest dietary changes.

The Nurses’ Health Study shows that these results are also seen in women, with lifestyle modification reducing the risk of sudden cardiac death (SCD). Many times, this is the first manifestation of heart disease in women. The authors looked at four parameters of lifestyle modification, including a Mediterranean-type diet, exercise, smoking and body mass index. The decrease in SCD was dose-dependent, meaning the more parameters adopted, the greater the risk reduction. SCD risk was reduced up to 92 percent when all four parameters were followed (8). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

How can you monitor your progress in lowering heart disease risk?

To monitor your progress, cardiac biomarkers, such as blood pressure, cholesterol, body mass index, and inflammatory markers like C-reactive protein can tell us a lot.

In a cohort study of high-risk participants and those with heart disease, patients began extensive lifestyle modifications: a plant-based, whole foods diet accompanied by exercise and stress management (9). The results showed improvements in biomarkers, as well as in cognitive function and overall quality of life. Most exciting is that results occurred over a very short period to time — three months from the start of the trial. Many of my patients have experienced similar results.

Ideally, if a patient needs medications to treat risk factors for heart disease, it should be for the short term. For some patients, it makes sense to use medication and lifestyle changes together; for others, lifestyle modifications may be sufficient, provided the patient takes an active role.

References:

(1) cdc.gov/heartdisease/facts. (2) Diabetes Care. 2010 Feb; 33(2):442-449. (3) Lancet. 2004;364(9438):93. (4) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (5) Hypertension. 2022;79:e1–e14. (6) JAMA. 2011;305(24):2556-2564. (7) J Nutr. March 1, 2005;135(3):556-561. (8) JAMA. 2011 Jul 6;306(1):62-69. (9) Am J Cardiol. 2011;108(4):498-507.

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.

Metro photo

By Leah S. Dunaief

Leah Dunaief

A local physician had a remarkable result. In clinical practice, he was treating a patient with severe migraines. The patient, 60 years old, had been experiencing migraines for 12 years. Recently they increased in frequency, and he was enduring six to eight debilitating headaches per month, each lasting more than 72 hours.  This equates to 18-24 headache days each month.

For those of us who suffer migraines, we know this must have been horrible. A migraine is not just a bad headache. It is as if a drill were unremittingly penetrating one spot in the head, all the while accompanied by nausea, vomiting and an inability to tolerate light. The aftermath is to feel hung over and unsteady. Migraines steal hours and days from the lives of the afflicted. 

The patient had tried various traditional medications, like zolmitriptan and topiramate to no avail. He also avoided possible migraine triggers like aged cheese, caffeine and red wine without success.

The internist, who specializes in lifestyle medicine, put him on a plant-based, high nutrient diet that he created of essentially low inflammatory foods every day. Hence he named it the LIFE diet, and its centerpiece is composed primarily of dark leafy greens, frozen blueberries, a banana and soy milk in a smoothie. These high fiber ingredients, when reinforced with flax seed meal, and a little pomegranate juice, can be made into a 32-ounce drink by a sturdy electric blender. The diet is further reinforced by eating more nutrient-dense veggies, like spinach, kale, arugula and romaine lettuce, for example, at subsequent meals in the day. These foods are thought to reduce chronic inflammation in the body.

The LIFE diet also limits dairy and red meat, whole grains, starchy vegetables and oils, according to reporter Sarah Jacoby, who interviewed the doctor for “Today” last Thursday, Nov. 18.

The results of the new regimen were dramatic. After two months, the patient was experiencing one headache per month. After three months, the headaches were gone. The patient suffered no further migraines. This result has lasted more than seven years so far.

At this point, the local physician, teaming up with his brother, who is a medical researcher, wrote up the study and sent it to the highly prestigious British Medical Journal or BMJ that publishes medical case studies deemed important. Delighted when it was accepted for publication, the doctor, who is a passionate believer in the healing power of dark green leafy vegetables, was further pleased when he learned that BMJ, considering the study valuable enough, had sent out a press release to publications all over the world with a summary.

The response was overwhelming, a testament to the need for a remedy to a universal malady. As of this writing, more than 40 news outlets across the globe, including UPI and WebMD, have picked up the story, from Europe to the Middle East to Asia and Australia, translating it into a dozen different languages.

“I think this (case report) is a tremendous start in the treatment of migraine headaches,” added the local physician. “This is kind of revolutionary to have the ability to say, ‘Not only does it work, but it works in the worst case scenarios. And it works in a short period of time.’”  He has seen similar results in other of his patients.

Dr. Charles Flippen, professor of neurology at the David Geffen School of Medicine at UCLA, agreed, stating that the change the patient experienced was, “rather impressive,” especially how long the effect has lasted. He added, “Now a large sample is necessary to draw conclusions about the benefits of diet change on migraines or chronic migraines,” as quoted by Sarah Jacoby for “Today.” 

Dr. Dawn Buse, clinical professor in the department of neurology at Albert Einstein College of Medicine in New York said, “There have been some recent studies suggesting that major dietary changes can reduce migraine symptoms,” according to “Today.”

“Even though we don’t know the exact mechanism for migraine, the concept of an inflammatory process as part of the underlying physiology of chronic pain has been around for decades,” explained Flippen. “So the idea that you have a diet that reduces the production of pro-inflammatory substances would fit nicely with our current understanding of migraine … It’s not purely magic that it worked.”

For the doctor, whose work has now circled the globe, the satisfaction is enormous. “I went into medicine to help people. It’s beyond gratifying that I may be helping people to take their lives back by reversing disease with the LIFE diet,” he concluded.  

And the name of the local internist who authored the study that has gone viral: my son and our own columnist, David Dunaief, MD.

A plant-based diet involving lots of vegetables, fruits and some grains may have a similar effect as steroids in reducing inflammation. Stock photo
Steroids reduce inflammation, but it comes at a cost

By David Dunaief, M.D.

Dr. David Dunaief

Steroid use as a performance-enhancing drug was a significant factor in the recent Olympics, with the Russian team banned for their illegal use. However, if we look beyond the flashy headlines to rudimentary use, we see that corticosteroids, or steroids, play an important role in medicine.

This is a commonly prescribed class of medications. In fact, our bodies make corticosteroids, the indigenous form of steroids, in the cortex of the adrenals, glands that sit on top of the kidneys. Here, we are going to concentrate on the exogenous form, meaning from the outside as medication.

Use or benefit

Steroids have an anti-inflammatory effect. This is critical since many acute and chronic diseases are based at least partially on inflammation. Chronic diseases that benefit include allergic, inflammatory and immunological diseases (1). These types of diseases touch on almost every area of the body from osteoarthritis and autoimmune diseases — rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, lupus, psoriasis and eczema — to asthma, COPD (emphysema and chronic bronchitis) and eye disorders. This type of medication is pervasive.

Delivery

Steroids are delivered orally, topically as creams, lotions and eye drops, or via injections, intravenous solutions and inhaled formulations. The most commonly known medication is prednisone, but there is a plethora of others, including prednisolone, methylprednisolone, cortisone, hydrocortisone and dexamethasone. Their benefits can be tremendous, improving functionality and reducing pain or improving breathing. You could say they are lifesaving in some instances, and with rescue inhalers they may just be that.

The bad

However, there is a very big caveat: they come at a price. Steroids have lots of adverse events associated with them. This is where the bad part comes in and keeps on coming. Steroids cause weight gain, increased glucose (sugars), high blood pressure, cardiovascular events, osteoporosis, change in mood (psychoses), cataracts, glaucoma, infection, peptic ulcers, Cushing’s syndrome and the list goes on. Ironically, steroids help with breathing; however, as I’ve seen in my clinical experience, they can cause shortness of breath when weaned from a longer-use high dose too quickly.

The upshot

The good news is that a plant-based diet may have similar beneficial effects in chronic diseases as steroids without all the downsides. Let’s look at the evidence.

The role in pneumonia

Pneumonia is among the top-10 leading causes of death in the world (2). It can be a most painful and debilitating disease. I know, for I experienced it personally while I was in my medical training. Every time I coughed, it felt like there was a fire in my chest.

In a meta-analysis (a group of nine studies), there was no overall effect of corticosteroids in reducing the risk of mortality in community-acquired pneumonia (3). However, don’t fret; when the data was broken into subsets, the findings were different. In subset data of those who had severe pneumonia, there was a statistically significant 74 percent reduction in mortality. And when duration was the main focus in subgroup analysis, those who received prolonged use of steroids reduced their risk of mortality by half.

Unfortunately, with the benefit comes an increased risk of adverse events, and this meta-analysis was no exception. There was a greater than two-times increased risk of abnormally high glucose levels with prolonged use. Thus, when giving steroids, especially for a prolonged use, it may be wise to check glucose levels.

In a more recent randomized controlled trial (RCT), the gold standard of studies, the results reinforced the beneficial effects of steroids on pneumonia. They showed that in those with both severe pneumonia and high inflammation, there was a two-thirds reduction in treatment failures when corticosteroids were added to the regimen (4). There were 120 patients involved in the study. They received antibiotics plus either methylprednisolone or placebo for five days.

Osteoarthritis: surprising results

As we know, osteoarthritis specifically of the knee is very common, especially as the population continues to age. Intra-articular (in the joint) injections directly into the knee are becoming routine treatment. A recent study compared injectable hyaluronic acid to injectable corticosteroid (5). The results showed that over three months, the corticosteroid was superior to hyaluronic acid in terms of reducing pain, 66 percent versus 43.8 percent, respectively. Interestingly, over the longer term, 12 months, hyaluronic acid reduced the pain and maintained its effect significantly longer than the steroid, 33 percent versus a meager 8.2 percent, respectively.

Study groups received five injections of either steroid or of hyaluronic acid directly to the knee over a five-week period. Thus, steroids may not always be the most effective choice when it comes to pain reduction. Hyaluronic acid may have caused this beneficial effect by reducing inflammation, protecting cartilage and preventing cell death, according to the authors.

COPD: length may not matter

It is not unusual to treat COPD patients with oral steroids. But what is the proper duration? The treatment paradigm has been two weeks with 40 mg of corticosteroids daily. However, results in an RCT showed that five days with 40 mg of corticosteroid was noninferior (equivalent) to 14 days of the same dosage and frequency (6). About one-third of patients in each group experienced a COPD exacerbation within the six-month duration of the trial. The hope is that the shorter use of steroids will mean fewer side effects. There were over 600 patients in this trial. We have come a long way; prior to 1999, eight weeks of steroids was a more commonplace approach to treating acute COPD exacerbations.

Topical steroid risk

Even topical creams and lotions are not immune to risk. For example, potent topical creams and lotions placed around the orbit of the eye with prolonged use may negatively affect vision (7). However, the evidence is based mostly on case reporting, which is a low level of evidence.

Dietary effect

One of the great things about steroids is that they reduce inflammation, and we know that the basis of greater than 80 percent of chronic disease is inflammation. A plant-based diet involving lots of vegetables, fruits and some grains may have a similar effect as steroids. The effect of diet on chronic disease may be to modify the immune system and reduce inflammation (8).

The bioactive substances from plants thought to be involved in this process are predominantly the carotenoids and the flavonoids. Thus, those patients who respond even minimally to steroids are likely to respond to a plant-based diet in much the same beneficial way without the downsides of a significant number of side effects. Diet, unlike steroids, can be used for a long duration and a high intake, with a direct relationship to improving disease outcomes.

In conclusion, it is always better to treat with the lowest effective dose for the shortest effective period when it comes to steroids. The complications of these drugs are enumerable and must always be weighed against the benefits. Sometimes, other drugs may have more beneficial effects over the long term, such as hyaluronic acid injections for knee osteoarthritis. A plant-based diet, with anti-inflammatory properties similar to steroids, may be a useful alternative for chronic disease or may be used alongside these drugs, possibly reducing their dosage and duration.

References: (1) uptodate.com.(2) N Engl J Med. 1995;333(24):1618-24. (3) PLoS One. 2012;7(10):e47926. (4) JAMA. 2015;313(7):677-686. (5) Open Access Rheum 2015;7:9-18. (6) JAMA. 2013;309(21):2223-31. (7) Australas J Dermatol. Mar 5, 2015. (8) Int J Vitam Nutr Res. 2008 Dec;78(6):293-8.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

Lifestyle modifications, particularly switching to plant-based diets, are effective tools in reversing diabetes.
Antioxidants in foods may reduce diabetes risk

By David Dunaief, M.D.

Type 2 diabetes continues to be an epidemic that is monopolizing health care budgets. According to the Centers for Disease Control and Prevention, the incidence of diabetes has tripled in the last 20 years (1). We need a plan to prevent the disease and to reverse its course.

In medicine, our arsenal of drug therapies has grown considerably, but there are unpleasant side effects. Drugs have even been shown to reduce cardiovascular disease in diabetes patients, which is the number one reason that patients die.

However, there is nothing potentially more powerful with beneficial side effects than lifestyle modifications, especially diet and exercise. And when it comes to reversal, lifestyle modifications are the only potential source.

Two large observational studies, the Adventist Health Study 2 and the EPIC trial, have shown the considerable prevention abilities of diet. In terms of reversal, several studies with a plant-based diet, including one run by Dr. Neal Barnard and another that I published with Dr. Joel Fuhrman, indicate its efficacy. These are backed up by additional anecdotal stories from my clinical experience over an 11-year period.

Let’s look at the research.

Prevention of diabetes with diet

Lifestyle modifications, particularly switching to plant-based diets, are effective tools in reversing diabetes.

A recently published prospective study of the E3N EPIC trial showed considerable benefit from the antioxidant capacity of foods including fruits, vegetables and tea (2). Those who consumed the highest quintile of antioxidants reduced their diabetes risk 39 percent compared to the lowest quintile. After adjusting for weight loss, there was still a statistically significant 27 percent reduction. Interestingly, fruits had the greatest impact with a 23 percent decrease in risk, and vegetables followed with a 19 percent decrease.

This study serves two purposes: one, it shows that antioxidant capacity is important in food; and two, it demonstrates that fruit actually has beneficial effects for those at risk of diabetes. This was not solely a plant-based diet or a vegan or vegetarian diet. This is an impressive effect considering that people may have been eating many other items that may not have been beneficial in addition to fruits and vegetables.

Study participants were 64,223 women who did not have diabetes or cardiovascular disease at the beginning of the study. One of the major weakness of this trial is that the food frequency questionnaire was only used at the study’s start. This means we have to assume people continued to eat the same way throughout the study.

In the Adventist Health Study, the results of a plant-based diet were very powerful. This showed significant effects and, unlike the EPIC trial, compared people who were trying to eat healthy with those who ate either a vegan or vegetarian plant-based diet. Results showed that those who ate a vegan plant-based diet and those who ate a lacto-ovo vegetarian diet were at 62 and 38 percent, respectively, lower risk of developing diabetes than those who were eating a health-conscious omnivore diet (3). This study reaffirms how a plant-based diet is so important when it comes to preventing diabetes.

There were 15,200 men and 26,187 women in this study, and the results were as impressive in both blacks and nonblacks.

Reversal of diabetes with diet

A randomized controlled trial, considered the gold standard of trials, used drug therapy to reduce HbA1C to near nondiabetes levels; however, they could not achieve this before multiple deaths occurred (4). The reason, the researchers surmise, was polypharmacy, or too many drugs.

Fortunately, this is not the case with lifestyle modifications. In one randomized controlled trial, Barnard compared a low-fat vegan diet to the American Diabetes Association diet at the time. The results showed that with a low-fat vegan diet, HbA1C was reduced significantly more than with the ADA diet (5). This trial included 49 patients on the low-fat vegan diet and 50 patients on the ADA diet. The trial duration was 74 weeks. This trial, though small, does show substantial benefit with a low-fat vegan diet.

The benefits of a plant-based diet have been known for many decades. In a 1979 study on diabetes, results showed that insulin was significantly reduced by more than half on a high carbohydrate, high-plant fiber diet (HCF) compared to a control diet (6). This effect was seen in approximately 2.5 weeks.

Involving 20 men with type 2 diabetes who had a mean duration with diabetes of 8 years, patients were started on the control diet for seven days and then switched to the HCF diet for 16 days. This showed reversal with diet over a short period of time and reduction in medication. Thus, diet does not only have an insidious (slow) effect, but it also has an acute (immediate) effect on diseases. Of course, insulin was the gold standard of treatment at the time.

More recently, in a retrospective (backward-looking) case series with 13 men and women with type 2 diabetes, results showed that HbA1C was reduced from a mean of 8.2 to 5.8 percent over a seven-month period (7). This was an impressive 2.4 percent reduction in HbA1C, and 62 percent of patients reached normal sugar levels.

At baseline, patients were on an average of four medications, including diabetes medications. By seven months, they were able to reduce this to one medication while significantly decreasing their HbA1C. In addition, their blood pressure and triglycerides improved. These patients were following a nutrient-dense, plant-based diet. This study was performed by myself and Fuhrman using patients in his practice. The study’s weaknesses were that there was no control arm and that it was retrospective. But this does imply that there is potential for diabetes reversal.

In my clinical practice, I have seen many diabetes patients successfully reverse their disease. Let me share one anecdotal story. A 55-year-old diabetes male Caucasian patient told me that no relative had lived past 57 because they died from diabetes complications. He is currently 60 years old or, as he likes to put it, “three years past expiration date.”

When he first came to see me, he was on four diabetes medications, including insulin, plus a statin. He is no longer on any of these medications. These results were seen in only two months. He did lose weight, but at a much slower pace than the metabolic changes that took place in his body. This anecdotal story is inspirational and reinforces the research above.

In conclusion, while medications are important for the treatment of diabetes, nothing seems to trump lifestyle modifications. Diet, especially, can play both prevention and reversal roles. Even fruit plays a significant role in reducing the incidence of diabetes. Regardless of family history, as demonstrated by my patient, these results can be achieved. Whether or not you are on medications, if you have diabetes, lifestyle modifications should be adopted to get optimal results.

References: (1) CDC.gov. (2) Diabetologia online Nov. 9, 2017. (3) Nutr. Metab Cardiovsc Dis. 2013;23(4):292-299. (4) N Engl J Med. 2008;358:2545-2559. (5) Am J Clin Nutr. 2009 May; 89(5): 1588S–1596S. (6) Am J Clin Nutr 1979 32: 2312-2321. (7) Open J Prev Med. 2012 2(3), 364-371.

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