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Yearly Archives: 2012

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Supplements may help, depending on the joint affected

Osteoarthritis (or OA) affects half of those over 60, significantly impacting quality of life for 27 million Americans. Historically, the disorder was thought to be solely a wear-and-tear degeneration of the joint(s). However, OA also involves inflammation with the release of cytokines and prostaglandins — inflammatory factors — which cause joint destruction and pain (Rheumatology. 2011;50(12):2157-2165).

The joints most commonly affected include the ankle, knee, hip, spine and hand. OA may affect joints asymmetrically, meaning that it affects a joint on only one side of the body.

One of the mainstays of treatment includes analgesics (painkillers), including acetaminophen and NSAIDs, such as ibuprofen (Advil), naproxen sodium (Aleve) and COX-2 inhibitors (Celebrex). These drugs may also improve joint mobility and NSAIDs have anti-inflammatory effects. There are adverse effects with NSAIDs, including increased gastrointestinal (or GI) bleed and, with long-term use, an increase in cardiovascular events, such as heart attacks, with the elderly being most susceptible. With chronic NSAID use, PPIs (acid-blocking drugs) may be appropriate to avoid GI tract complications (BMC Family Practice 2012;13:23).

Neither medication type, however, structurally modifies the joints. In other words, they may not slow OA’s progression nor rebuild cartilage or the joint space as a whole. Are there therapies that can accomplish these feats and, if so, what are they? We will look at hyaluronic acid, glucosamine and chondroitin, and lifestyle modifications such as exercise and weight loss.

Chondroitin sulfate beneficial for hand OA

The results with the use of glucosamine and chondroitin have been mixed, depending on the joints affected. In the FACTS trial, a randomized controlled trial, chondroitin sulfate by itself showed significant improvement in pain and function with OA of the hand (Arthritis Rheum. 2011 Nov;63(11):3383-91). The dose of chondroitin used in the study was 800 mg once a day. The patients, all of whom were symptomatic at the trial’s start, also saw the duration of their morning stiffness shorten.

There was also a modest reduction in structural damage of hand joints, compared to placebo. The benefit was seen with prescription chondroitin sulfate, so over-the-counter supplements may not work the same way. Patients were allowed to use acetaminophen, and there was no change in dose or frequency throughout the trial. An effect was seen within three months.

Crystalline glucosamine sulfate

In knee OA, crystalline glucosamine sulfate showed reduction in pain and improvement in functioning in an RCT (Ther Adv Musculoskel Dis. 2012;4(3):167-180). When assessed by radiologic findings, it also slowed the progression of structural damage to the knee joint. In other words, the therapy may have disease-modifying effects over the long term. The glucosamine formulation may work by inhibiting inflammatory factors such as NF-kB. The trial used 1500 mg of prescription crystalline glucosamine sulfate over a three-year period. Again, it’s not clear whether an over-the-counter supplement works the same way.

Glucosamine and/or chondroitin for knee OA

In a meta-analysis (group of 10 studies), glucosamine, chondroitin or the combination did not show beneficial effects — reduced pain or mobility changes — in patients when compared to placebo (BMJ. 2010;341:c4675). It was not clear whether supplemental or prescription-level therapies were used in each trial — or whether that makes a difference. This study was published prior to the crystalline glucosamine sulfate trial of the knee, discussed above, which did show statistical significance.

There is not much downside to using glucosamine and/or chondroitin for OA patients. However, use caution if taking an anticoagulant (blood thinner) like Coumadin, since glucosamine has anticoagulant effects. Also, those with shellfish allergies should not use glucosamine. If there is no effect within three months, it is unlikely that glucosamine and/or chondroitin are beneficial.

Hyaluronic acid

In a meta-analysis (a group of 89 trials), the risks outweighed the benefit of hyaluronic acid, a drug injected into the joint for the treatment of OA (Ann Intern Med. online June 12, 2012). Viscosupplementation involves a combination of hyaluronic acid types that act as a shock absorber and lubricant for the joints. Some of the studies did show a clinical benefit. However, the authors believe that adverse local events, which occurred in 30 to 50 percent of patients, and serious adverse events, with 14 trials showing a 41 percent increased risk, outweigh the benefits. Since there are mixed results with the trials, it is best to discuss this option with your physician.

Impact of weight loss and exercise

No matter where you look, obesity is involved in many chronic diseases. OA is no exception. Obesity treatment with a weight-loss program actually has potential disease-modifying affects (Ann Rheum Dis. 2012;71(1):26-32). It may prevent cartilage loss in the medial aspect of the knee. The good news is that, even with as little as a 7 percent weight loss in the obese patient, these results were still observed. The average weight loss was nine to 10 pounds. It was a dose-response curve — the greater the weight loss, the thicker the knee cartilage.

There was a separate study done with computer modeling showing that obesity reduces quality of life by 12 percent and that OA has a negative impact on the quality of life by about the same amount. Interestingly, the combination decreases the quality of life by 25 percent (Ann Intern Med. 2011; 154(4):217-26). Losing weight would also reduce the number of knee replacements, according to the study.

According to Dr. David Felson, a rheumatologist at Boston University School of Medicine who commented in The New England Journal of Medicine, there is an inverse relationship between the amount of muscle-strengthening exercise, especially of the quadriceps, and the amount of pain experienced in the knee joint. It is very important to do nonimpact exercises such as leg raises, squats, swimming, bicycling and on elliptical machines.

Fortunately, there are a number of options to prevent, treat and potentially modify the effects of OA. With weight loss in the obese patient, quality of life can dramatically increased. Glucosamine and/or chondroitin may be of benefit, depending on the joints affected. The benefits are potential improvements in pain, mobility and structural-modifying effects, which are worth the risk for many patients. When taking glucosamine and/or chondroitin in supplement form, ConsumerLab.com may be a good source for finding a supplement where you get the dose claimed on the box. I would also use formulations in the trials that showed results, even in supplement form.

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, go to www.medicalcompassmd.com and/or consult your personal physician.

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Amid the moving chaos of New York City, Thomas Watson has stopped and watched the steam that rises out of manholes. On one side of the street, the steam drifted one way.

On the other, it headed in the opposite direction.

While the complexity of the wind might seem fitting for a city where people blow in from all over the world, the shifting air currents are much more than a metaphor to the chemist from Brookhaven National Lab. They have become a part of research he — and emergency management personnel in the city — use to understand how gases, particularly toxic or dangerous ones, might move through the street canyons created by buildings of all shapes and sizes.

In 2005, Watson conducted an extensive study of air currents in and around the city. He released perfluorocarbons at different points throughout the area, tracked where the gases went and put together how they might have gotten from one place to another.

This year, he’s starting another similar study. His work, which in 2005 was funded in part by the Department of Homeland Security, is designed to help emergency management crews in the city deal with an accidental release of gases that might pose a threat to public safety. The city also uses his research in the event of the intentional release of harmful substances.

“The research we do supports emergency response decision making,” said Watson.

Watson leads a unit at BNL called the Tracer Technology Group. They release harmless gases to see how different elements travel under a broad range of meteorological conditions.

The gases, called perfluorocarbons, are “totally nonreactive” and can be detected at incredibly low levels: parts per quadrillion.
Tracer gases are sometimes used across much larger areas than a metropolitan region as well.

“We can get an idea of how air is moving across the continent,” he suggested.
In the Across North America Tracer Experiment (Anatex) in the late 1980s, for example, gases released from Glasgow, Montana and St. Cloud, Minn., could be seen on the East Coast.

The science of tracking air movements using tracer compounds as they move across different terrains started about 30 years ago, Watson recalled, as part of a comprehensive safety plan amid the development of nuclear power plants. While a release from a plant is unlikely, “prudence dictates we should be able to predict where a release would go,” Watson offered.

Watson also studies indoor air quality, looking at infiltration rates into buildings. The ventilation systems of large buildings, he explained, often bring outside air into the system at a measured rate.

This work not only has implications for safety and public health, but also for energy efficiency, as buildings can use the data he collects to figure out whether more outside air than anticipated is entering the building. On a particularly hot or cold day, the introduction of outside air could raise heating or cooling costs.

Watson has also been involved in finding leaks in underground systems for utility companies. In some of the subterranean systems, power companies have underground wires that are surrounded by oil, which helps insulate and provide some cooling. When the oil leaks, it’s difficult to find. Enter perfluorocarbons.

“We ride around in a van and can find [the perfluorocarbons],” he described. By tracking the gases, “we can come within a couple of feet of the leak.”

The alternative to using the tracer chemicals is to freeze the line and see where the pressure drops. The freeze method sometimes requires digging several holes before finding the leak.

Tracer gases are also “important for climate work,” Watson offered. He looks at the exchange between the biosphere and the atmosphere. He validates transport models used to help interpret carbon dioxide exchange measurements.
When Watson, who lives in Ridge with his wife Phyllis, isn’t tracking gases through the air or underground, he enjoys spin casting for striped bass. He said he usually keeps one a season.

Although he grew up in Delaware and was a Phillies fan, he has seen the error of his ways and, after seven years on Long Island, has seen his allegiance drift to the Mets.

As for his work, Watson is convinced he’s doing something important and that he needs to provide the best possible information to emergency personnel.

“No scientific data is ever exact to an infinite number of decimal places,” he concedes. “We strive to get the best possible information to all our sponsors and always provide uncertainty limits.”

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Vitamin D may reduce risk in skin cancer patients; mixed cardiovascular results

Vitamin D is one the most widely publicized and important supplements. We get vitamin D from the sun, food and supplements. Since summer is now in full swing and the beaches are open, I thought it would be appropriate to share some recent findings.

Vitamin D has been thought of as an elixir for life, but is it really? There is no question that, if you have low levels of vitamin D, repleting (replacing) it is important. Previous studies have shown that vitamin D may be effective in a wide swath of chronic diseases, both in prevention and as part of the treatment paradigm. However, many questions remain. As more data come along, their meaning for vitamin D becomes murkier.

The sun

For instance, is the sun the best method to get Vitamin D?
At the 70th annual American Academy of Dermatology meeting, Dr. Richard Gallo who was involved with the Institute of Medicine recommendations, spoke about how, in most geographies, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water, fatty fish such as salmon, sardines and tuna.

We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular and autoimmune diseases and cancer.

There is no consensus on the ideal blood level for vitamin D. The Institute of Medicine recommends more than 20 ng/dl, and The Endocrine Society recommends at least 30 ng/dl. More experts and data lean toward the latter number.

Skin cancer

Vitamin D did not decrease non-melanoma skin cancers (known as NMSCs), such as squamous cell and basal cell carcinoma. It may actually increase them, according to one study done at a single center by an HMO (Arch Dermatol. 2011;147(12):1379-84). The results may be confounded, or blurred, by UV radiation from the sun, so vitamin D is not necessarily the culprit. Most of the surfaces where skin cancer was found were sun exposed, but not all of them.

The good news is that, for postmenopausal women who have already had an NMSC bout, vitamin D plus calcium appears to reduce its recurrence, according to the Women’s Health Initiative study (J Clin Oncol. 2011 Aug 1;29(22):3078-84). In this high-risk population, the combination of supplements reduced risk by 57 percent. Unlike the previous study, vitamin D did not increase the incidence of NMSC in the general population. NMSC occurs more frequently than breast, prostate, lung and colorectal cancer combined (CA Cancer J Clin. 2009;59(4):225-49).

Cardiovascular mixed results

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (Circulation. 2008 Jan 29;117(4):503-11).

However, a recent small randomized controlled trial, the gold standard of studies, calls the cardioprotective effects of vitamin D into question (PLoS One. 2012;7(5):e36617). This study of postmenopausal women, using biomarkers, such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study endpoints. However, these results do make you think.

Weight benefit

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (J Womens Health (Larchmt). 2012 Jun 25).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.

Mortality decreased

In a recent meta-analyses (a group of eight studies), vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (J Clin Endocrinol Metabol. online May 17, 2012). The difference between the groups was statistically important, but clinically small: 9 percent reduction with vitamin D plus calcium and 7 percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large boluses (amounts) of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

USPSTF recommendations

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women the combination of vitamin D 400 IUs plus calcium 1000 mg to prevent fractures (AHRQ Publication No. 12-05163-EF-2). It does not seem to reduce fractures and increases the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

Need for clinical trials

We need clinical trials to determine the effectiveness of vitamin D in many chronic diseases, since it may have beneficial effects in preventing or helping to treat them (Endocr Rev. 2012 Jun;33(3):456-92). Right now, there is a lack of large randomized clinical trials. Most are observational, which gives associations, but not links. The VITAL trial is a large RCT looking at the effects of vitamin D and omega 3s on cardiovascular disease and cancer. It is a five-year trial, and the results should be available in 2016.

When to supplement?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it may play an integral role with many disorders.

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, go to www.medicalcompassmd.com and/or consult your personal physician.

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Professor’s study of lemurs helps them, conservation and medicine

Patricia Wright loves Madagascar and its lemurs — and the country returns the favor. On July 2, Wright will inaugurate a state-of-the-art, four-story research center adjacent to a rainforest — complete with a high-speed Internet connection. At the same time, the Stony Brook anthropology professor will receive her third Legion of Honor medal, becoming the first foreigner to receive three of the island nation’s highest awards.

The star-studded opening of the facility — called Namanabe (for Friendship) Hall — will have over 600 guests. The attendees span the world, from Stony Brook President Samuel Stanley, to Madagascar’s minister of the environment, to the vice rector of the University of Helsinki, Finland, to the ambassador for the U.S. to Madagascar, Eric Wong, to local kings from 33 villages, and 21 traditional healers.

The building, which overlooks a waterfall, river and rainforest and has a garden and solar panels on the roof, will provide a home for the study of biodiversity and infectious disease.

Wright, who has been studying lemurs since 1985, will soon announce that there are three kinds of dwarf lemurs in nearby Ranomafana National Park. Previously, scientists believed the park only contained one species of dwarf lemur. Ranomafana has 14 species of lemurs, one of the highest counts for a single park in the world.

Wright has a long list of notable achievements in her studies of the Madagascar primates, whose name comes from the lemures of Roman mythology because of the animal’s ghostly calls and reflective eyes.
In the 1980s, Wright was searching for the greater bamboo lemur, which some scientists believed had become extinct. She not only found the endangered animal, but also discovered the golden bamboo lemur, a species scientists didn’t even know existed.

For the second year in a row, she was a finalist in the $100,000 Indianapolis Prize, the top award for animal conservation. While she didn’t win this year, she was one of only six finalists from a competitive field of conservation biologists.

“It’s a great honor,” said Wright. “Many fantastic people are on that list that have done amazing things. I’m proud to be a part of that.”

Stuart Pimm, the Doris Duke professor of conservation at Duke University, called Wright “Madagascar’s savior” for working to conserve an environment scientists describe as the “eighth continent” for its remarkable diversity of species, some of which are threatened or going extinct.

“Nobody does conservation work in Madagascar without coming under her influence,” Pimm declared. The new research facility Wright helped build is “an amazing meeting house for people who want to protect the Malagasy environment. That contribution will last for decades. It’s a very tangible achievement.”

Wright explained that her current research, which she conducts in Ranomafana, addresses three questions. First, she is studying lemur behavioral ecology and demography and aging in the wild.

Second, she is looking closely at the mouse lemur, the world’s smallest primate. Some mouse lemurs in captivity, who were as young as four years old, developed Alzheimer’s. She is tracking 500 mouse lemurs in the wild. So far, she has examined wild mouse lemurs as old as 10 and hasn’t found any similar cases. That could be because lemurs that suffer from age-related cognitive problems could become easier targets for predators. It also could be related to the mouse lemur’s diet or to its more active lifestyle in the rain forest.

And, finally, she is examining seed dispersal in trees by lemurs. She’s planning to study how far away seeds get from the parent tree. She also wants to see if seeds from a wide range of canopy trees with large, sweet fleshy fruits that pass through the digestive system of a lemur sprout faster and live longer.

“We’re really interested in ecosystem dynamics,” she explained. “To really understand how to restore a habitat, we have to know how it works to begin with. That’s not easy in a rainforest.”

Although she applies science to just about everything she does professionally, Wright knows she needs much more than good intentions and a clipboard to wander through the rainforest to study lemurs.

“Whenever you are exploring in new places, when you meet people, you have to be a little cautious: they don’t know who you are and you don’t know who they are. You have to obey the rules of the local culture,” she explains.

She visits with the village elders first, to describe what she’s doing. She travels with permits signed by authorities. She has put considerable effort into sharing information about the rainforest and about health with the Malagasy (the name for people from Madagascar).

“When we’re dealing with health, we like to have it science-based,” she said. “We’re not just dispensing pills. We like to do health and hygiene education to prevent health problems before they happen.”
In addition to her scientific contribution, Wright has helped build and shape communities around the rainforest, Pimm said.

“She has done an extraordinary job in ensuring that people in the local community benefit from having a national park right next to them,” observed Pimm, who has known Wright for more than 15 years. “There is now a community of small businesses that have learned through [her] leadership.”

In addition to respecting the people in the remote areas where she treks — often on foot and while carrying her own food and cooking utensils — Wright remains aware of other threats.

“I’m quite a careful person for someone who does all these crazy things,” she offered.

Indeed, she has encountered the deadly fer-de-lance snake — a reptile whose venom can be fatal to humans. Always on the lookout for the deadly snakes, she has seen them several times. She was on a trail following monkeys one night when she encountered another dangerous creature. She explained that the path was wet, so neither one could hear the other coming. She rounded a bend and stopped inches from a jaguar.

“There we were, eye to eye,” she recounted. “I thought to myself: that animal is bigger than me. I’m getting off the trail.”

The predatory cat jumped away, perhaps because a headlight Wright wore to navigate through the soggy jungle confused him.

While assiduously avoiding jungle cats, Wright has tried to attract sponsors for her research.

In April, she held a rock concert at Centre Valbio, where the U.S. Embassy invited some of the wealthiest people in the country to enjoy music by popular Malagasy bands while learning about research in the rainforest.

“What I actually do is very complex,” she explained. “It’s very important that the science is not done in a vacuum. It has to be incorporated into public awareness.”

As for the future, Namanabe Hall, Wright hopes, is just another step in research and conservation in Madagascar.

“There are so many things we need to make the research dream come true,” she offered. “I would love to put sensors out into the forest that could stream back to our network and databases information on microclimate and animals. The Namanabe Hall is just the beginning of what I hope will be a fountain of inspiration to study this tropical rainforest in innovative ways and to study and assist the people, too.”

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Some animal sources increase gout while plant sources may not

Gout is thought of as an inflammatory arthritis. It occurs intermittently, affecting the joints, most commonly the big toe. The symptoms are acute (sudden onset) and include extremely painful, red, swollen and tender joints. Uric acid (or urate) levels are directly related to the risk of gout attacks. As uric acid levels increase, there is a greater chance of urate crystal deposits in the joints.

This disease affects more than three million people in the U.S. (Arthritis Res Ther. 2006;8:Suppl 1:S2). Men between 30 and 50 years old are at much higher risk for their first attack. For women, most gout attacks occur after menopause.

There are a number of potential causes of gout, as well as ways to prevent and treat it. Though heredity plays a role, these risk factors are modifiable. The best way to prevent and treat gout is with medication and lifestyle modifications.

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

Animal versus plant proteins

In a recent case-crossover (epidemiologic forward-looking) study, it was shown that purines from animal sources increase the level of purines far more than those from plant sources (Ann Rheum Dis. online May 30, 2012). The risk of a gout incident was increased approximately 241 percent in the group consuming the highest amount of animal products, whereas the risk of gout was still increased for those consuming plant-rich purine substances, but by substantially less: 39 percent.

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

In another study, meats — including red meat, pork and lamb — increased the risk of gout, as did seafood (NEJM 2004;350:1093-1103). However, purine-rich plant sources did not increase risk of gout. Low-fat dairy actually decreased the risk of gout by 21 percent. The study was a large observational study involving 49,150 men over a duration of 12 years. Therefore, it is unlikely that the patient switching to a nutrient-dense, plant-rich diet increased her risk of gout.

Diuretics (water pills)

My patient was on a diuretic called hydrochlorothiazide for hypertension (high blood pressure). There are several medications thought to increase the risk of gout, including diuretics and chronic use of low-dose aspirin. In the ARIC study, patients who used diuretics to control blood pressure were at a 48 percent greater risk of developing gout than nonusers (Arthritis Rheum. 2012 Jan;64(1):121-9). In fact, nonusers had a 36 percent decreased risk of developing gout. This study involved 5,789 participants and had a fairly long duration of nine years. The longer the patient is treated with a diuretic, the higher the probability they will experience gout. It is likely that my patient’s diuretic contributed to her gout episode.

Medical conditions

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

Obesity

Obesity, like smoking, seems to have its impact on almost every disease. In the CLUE II study, obesity was shown to not only increase the risk of gout but also accelerate the age of onset (Arthritis Care Res (Hoboken). 2011 Aug;63(8):1108-14). Those who were obese experienced gout three years earlier than those who were not. Even more striking is the fact that those who were obese in early adulthood had an 11-year earlier onset of gout. The study’s duration was 18 years. My patient was obese and had started to lose some weight before the gout occurred.

Vitamin C

Vitamin C may reduce gout risk. In the Physicians Follow-up Study, a 500 mg daily dose of vitamin C decreased levels of uric acid in the blood (J Rheumatol. 2008 Sep;35(9):1853-8).

Prevention

The key to success with gout lies with prevention. Patients who do get gout writhe in pain. Luckily, there are modifications that significantly reduce the risks. They involve very modest changes, such as not using diuretics in patients with a history of gout, losing weight for obese patients and substituting more plant-rich foods for meats and seafood. Although the cause of gout may be apparent to you, always check with your doctor before changing your medications or making significant lifestyle modifications as we have learned from this case study of my patient.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Moderate exercise for a moderate amount of time may be the most effective

Most of us, myself included, have a love-hate relationship with exercise. Sometimes it’s difficult to get motivated or carve out the time, however, the feeling afterward can be rejuvenating. For the longest time, with a few exceptions, the belief has been that exercise always has positive effects. However, this may not be the case for everyone, according to a new study’s findings. Let’s look at the potential downsides and upsides of exercise, as well as the optimal workout intensity.

The downsides of exercise

Those with certain diseases, such as heart failure and hypertrophic cardiomyopathy, need to be especially cautious when exercising. However, when heart failure patients do exercise, some trials, like the HF-ACTION trial, show improvements in symptoms, exercise capacity and quality of life (J Am Coll Cardiol. 2011;58:561-569).

A new study suggests that exercise may have negative cardiovascular and diabetes impacts on 10 percent of the population (PLoS One. 2012;7(5):e37887. Epub 2012 May 30). That’s scary. To make matters worse, the effect was random — there was no one cohort or group affected. When you analyze the study, however, there are some potential weaknesses.

The study endpoints included biomarkers, such as HDL “good” cholesterol levels, blood pressure, triglycerides and insulin levels. Many things can affect these endpoints. For example, I had a patient who exercised in the morning, yet his blood glucose (sugar) was worse postexercise. It turned out he was drinking pomegranate juice before exercising, which increased his glucose levels.

Also, as I mentioned in last week’s article, the cholesterol marker, HDL, may not have protective effects nor be directly correlated to cardiovascular disease. Therefore, we really don’t know what it means when HDL levels go down with exercise.

Better endpoints for this study would have been outcomes measurements, such as overall mortality, cardiovascular mortality and morbidity (sickness), and cardiovascular event rates. I worry, as do others, that people may use this study as an excuse not to exercise. I think the message should be: Use caution when exercising, but do exercise. Let’s look at why.

The upsides

We know that exercise has tremendously positive impacts on a multitude of diseases and disorders, such as obesity, heart disease, stroke, diabetes, Alzheimer’s, rheumatoid arthritis, migraines and cancer.

One recent study shows exercise is directly related to improvements in sleep (Am J of Med. 2012;125(5):485-490). In the epidemiologic study, the hours of exercise a week decreased the occurrence of mild and moderate sleep-disordered breathing 24 percent and 33 percent, respectively. The opposite was also true: As the hours of exercise declined in some patients, sleep-disordered breathing worsened.

What about longevity?

There are two recent studies that show exercise helps to improve longevity. In the Copenhagen City Heart Study, the results showed that light jogging at a slow to moderate pace for 1 to 2 1/2 hours a week was ideal. The mean increase in longevity was 6.2 years in men and 5.6 years in women. Even elderly patients saw longevity improvements. There were improvements in insulin levels, bone density and lipid profiles which contributed to the longevity effect. This study was observational, with 20,000 participants over a 35-year duration (EuroPRevent 2012: Abstract). The good news is that you don’t have to be an elite athlete to achieve the increased longevity.

In a second study, those who jogged at a modest pace saw a three-year increase in longevity. Those in the “low volume” activity group, defined as 92 minutes of exercise per week, realized a 14 percent reduction in the risk of death and a three-year increase in life expectancy when compared to the sedentary group (Lancet. 2011 Oct 1;378(9798):1244-53). In other words, 15 minutes of exercise a day has a powerful effect on longevity. This was a very large prospective (forward-looking) observational study.

How best to approach exercise?

In a study presented at the American College of Sports Medicine, there was a 19 percent reduction in the risk of mortality for those who “ran” at a modest pace — defined as 5.5 to 6 miles per hour, or a 10- to 11-minute mile — compared to those who did not run, those who ran more than 20 miles per week, and those who ran faster than 7 mph (although the last two groups were less common). This benefit was seen as long as participants ran between 1 and 20 miles per week. Therefore, a modest distance at a modest pace resulted in the most benefit. This study was part of the Aerobics Center Longitudinal Study at the Cooper Institute in Dallas, Texas.

Thus, it appears that the benefits of exercise far outweigh the risks, even in patients who have heart failure. The most beneficial levels of exercise seem to be in the modest zone for both duration and intensity. This does not mean you can’t exercise with more intensity, with your doctor’s permission. However, it does imply that inactivity is far more dangerous than exercise: There are several studies showing that inactivity reduces longevity and increases cardiovascular events.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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SBU professor R. Lawrence Swanson uses hair conditioners as chemical markers to study sewage

Hair conditioners aren’t just helpful for the heads of Hempstead residents. They also serve as chemical markers for what happens to sewage released through the Bay Park outfall in Reynolds Channel.

That’s just one of a host of findings in an ongoing study of Hempstead sewage that Stony Brook University professor R. Lawrence Swanson is managing. Swanson is leading a group of 10 scientists and three graduate students who are examining the Western Bays in Hempstead to determine what’s happening in the area and to recommend what actions, if any, policy-makers might need to take to protect the region.

While the hair care chemicals, which Stony Brook associate professor Bruce Brownawell is studying, aren’t necessarily damaging to the environment, they do act as markers for the bay.

“Looking at the results of hydrodynamic modeling in conjunction with some of the work that’s been done looking at hair care [products] in sediments has indicated to virtually all of us that the removal of material from the vicinity of the Bay Park outfall is not very good,” Swanson stated. “There’s a lot of sloshing back and forth in the Reynolds Channel.”

Swanson suggested that the choice of the channel in the 1950s probably seemed like a logical one because tidal currents are “quite rapid” twice a day. However, the problem is that “much of that water seems to slosh back and forth, as opposed to exiting.”

Just as the sewage begins to drift east and north away from the bays, the tidal current reverses and pushes it back. Swanson explained. The residence time in Reynolds Channel is between 50 and 240 hours. That means a particle released in the channel would take that long to leave the general area, Swanson said, citing the work of Stony Brook associate professor Robert Wilson.

Additionally, Reynolds Channel and areas to the north are struggling with a “tremendous biomass of sea lettuce,” Swanson observed.

While sea lettuce is common around Long Island, it is so dense in those areas that residents are referring to it as “green bergs.” It accumulates at Point Lookout near the entrance to Jones Inlet to such an extent that the hydrogen sulfide smell is noticeable.

The Hempstead Bays project, which started in September of 2010, runs through March 2013. At the end of it, Swanson and the rest of his team will summarize the results and make recommendations to policy-makers.
As he enters his fourth decade in the environmental sciences at Stony Brook, Swanson indicated he has become increasingly outspoken about the dangers of poor waste management.

“We’re in trouble,” Swanson declared. “We have reached our limit in terms of population growth. In Suffolk County, we are still relying on septic systems that are not the best technology. Many of them are probably not functioning particularly well.”

Swanson said the nitrogen concentration in the Magothy aquifer is about 200 times greater than it was in the 1980s, citing data from the Suffolk County Health Department. The Magothy aquifer is the largest bed of permeable rock that provides water to Long Island.

Still, Swanson isn’t ready to give up on Long Island or on the possibility of improving an environment he said he has thoroughly enjoyed since moving here in 1973.

Swanson lives in Head of the Harbor with his wife, Dana, who is an artist. One son, Michael, lives in St. James, while Larry lives in Seattle, where Dana grew up and where her extended family has lived for four generations.

The Swansons live in a 170-year-old house that was the site of a water bottling business known as the Soper Bottling Works in the late 1800s.

“Every day, the house wakes up and says, ‘What are you going to do for me today?’” laughed Swanson.

Swanson is optimistic that the right programs and approach can improve the environment. He points to the New York Bight, a region between Cape May and Montauk where ocean dumping occurred until around 1990.
Since the cessation of dumping, “You would see a remarkable resilience of the marine environment and its ability to recover, once we stop abusing it.”

Swanson cautions against continued environmental abuse. “An ounce of conservation is worth many pounds of restoration,” he offered.

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Mom was right again: Eat your breakfast and your fruits and veggies

Diabetes is always on the medical radar screen. As incidence of the disease continues to grow, there is a constant stream of new research on the topic. One thing you can say definitively about diabetes:  it never gets dull. The American Diabetes Association meeting in June did not disappoint, revealing both good and bad news.

Fortunately, the good news is abundant. Most importantly, mortality decreased 23 percent overall in diabetes patients and 40 percent in diabetics with cardiovascular disease when comparing 2006 and 1997 results, according to a Centers for Disease Control  survey (Diabetes Care June 2012 vol. 35 no. 6 1252-1257). The author of the study warns, however, that diabetics are still at increased risk for severe complications.

Breakfast’s impact

Mothers always struggle to get their children to eat breakfast. In this case, Mom may be onto something. In a study of almost 4,000 participants, ages 27 to 35 years old, those who ate breakfast were less likely to develop type 2 diabetes (ADA June 2012, abstract 1364-P). For each breakfast consumed during the week, there was a 5 percent reduction in risk. When the researchers compared those who ate breakfast at least five times a week to those who ate it three or fewer times a week, the risk of developing type 2 diabetes fell 31 percent among the frequent breakfast eaters. Those who ate breakfast more frequently did not gain as much weight, 0.5 kg/m2. BMI played a role in this effect. This is an easy way to help ward off diabetes, as well as get you charged for the day.

Insulin and cancer

There have been concerns that insulin increases the risk of cancer. However, in three very large epidemiologic studies presented at the ADA meeting, there was no significant association between the use of glargine insulin and an increased risk of cancer, when compared to other insulins (ADA June 2012, abstract CT-SY13).

However, there are caveats to these studies. For instance, why they compared glargine to other insulins and not to oral drugs seems to weaken the study’s conclusions. There were also slight, but non-significant, increases in breast cancer, 12 percent, and prostate cancer, 11 percent, in one of the studies. The studies’ durations were not very long when you consider the length of time it takes to develop cancer. They ranged from 1.2 years to 3.1 years with glargine and 1.1 years to 3.5 years with other insulins. Hence, I think it is important to interpret the results with a bit of skepticism, though they do point in the right direction.

Metformin and B12 deficiency 

Yet another study presented at the ADA found that those diabetes patients who are taking metformin and have B12 deficiencies have a much higher risk of developing peripheral neuropathies (tingling, numbness and pain in the extremities) that may lead to permanent nerve damage (ADA June 2012, abstract 954-P). Chronic metformin use may be a contributing factor to the B12 deficiency. Before attributing the symptoms to diabetic neuropathy, it is important to test patients’ B12 and methylmalonic acid levels. As age increased, not surprisingly, the likelihood of B12 deficiency also increased. For more information on the appropriate levels of B12, please see my May 1, 2012 article.

Fruit and vegetable effect

Those patients who consumed the most fruits and vegetables saw a 21 percent reduction in risk of diabetes, compared to those who consumed the least, according to the EPIC study (Diabetes Care 2012;35(6):1293-1300). Quantity was important with vegetables, showing a 24 percent lower risk in those who ate the most, but quantity did not play a role in fruits. More important to fruit was the variety, with a 30 percent reduction in those with the most diversity in fruit intake. Combining varied fruits and vegetables resulted in the greatest reduction, 39 percent.

Omega-3 Fatty acids

In a recent randomized controlled trial omega-3 (fish oil) supplements showed disappointing results (NEJM online June 11, 2012). Supplementation with 900 mg of omega-3s did not reduce the incidence of stroke, heart disease or death from cardiovascular disease in pre-diabetes or diabetes patients. This dose may be too low, but still it is unlikely that taking omega-3s will reduce the risk of strokes or heart attacks in diabetes patients. I wrote a two-article series, starting on May 22, 2012, that showed omega-3s were effective in some diseases, but not in others. Therefore, there are more efficient ways to treat diabetes than with fish oil.

Thus, the moral of the story is that lifestyle modifications are an important ingredient in preventing and treating diabetes. If you are taking insulin, you can breathe a sigh of relief that it may not increase your risk of cancer. Make sure to test B12 levels, especially if you are taking metformin, and don’t rely on fish oil to prevent complications from diabetes or pre-diabetes. And as my mom always says, eat your breakfast.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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SBU professor Scott McLennan part of team studying ancient Martian rocks to understand its geology

Terrestrial trucks with tough names and gritty commercials have nothing on a six-wheeled golf cart-sized vehicle. Operating millions of miles away on the unforgiving surface of Mars, the rover, Opportunity, landed in 2004 and was only expected to last for three months.

Eight years later, Opportunity is going strong, sending back useful information about the red planet. Using solar power, Opportunity outlasted its twin, Spirit, which stopped responding to Earth-bound signals about two years ago. The scientific vehicle recently provided even more evidence that Mars once not only had water, but that the water may have contained life.

Venturing near the Endeavour crater (named after the British ship that explorer James Cook led to New Zealand and Australia at around the same time as the American Revolution), Opportunity found rocks and minerals that provided more clues about the evolution and history of the surface of Mars.

“When we came onto the rim of the Endeavour crater, the fundamental geology completely changed,” explained Stony Brook University geochemistry professor Scott McLennan, who recently teamed up with scientists at several institutions to publish a paper in Science on their findings.

Looking at rocks that are likely older than 3.8 billion years old, McLennan and other scientists found extremely high zinc contents. Usually, zinc is at a level of 30 to 300 parts per million, but in these rocks, zinc was closer to 6,300 parts per million.

Zinc combines with sulfur and phosphorous. Scientists would expect to find these minerals, such as zinc sulfide or zinc phosphate, in rocks that had hydrothermal fluids that ran through them.

“People have known there was water on Mars for a long time,” McLennan explained. “The real issue was whether the water was in a liquid form at a time when you could have had environments in which life could have survived. We’re finding more geological environments in which water was active and conditions could have been habitable.”

Scientists also discovered gypsum near the crater. The chemical name for this mineral is calcium sulfate dihydrate. The last part of that name means the mineral has two water ions per molecule embedded in it.

“This was completely unexpected,” said McLennan.

Finding water tied up in the structure of minerals and rocks means they could become a resource for future exploration of Mars. For astronauts to make a round trip, they would need to make use of whatever water and fuel they could extract from Mars.

McLennan cautioned, however, that the volumes of water in the minerals on Mars are “not great.” Indeed, for every kilogram of gypsum, scientists could likely remove just over 200 grams (or 20 percent of the mineral’s weight) in water.

Much of McLennan’s research comes from analyzing the information sent back from Mars and simulating what he sees in his Stony Brook lab.

“What we were able to do,” said Joel Hurowitz, a research scientist at Jet Propulsion Laboratory who worked in McLennan’s lab to earn his doctorate, “was go into one lab and make rocks in a furnace and then take them to another lab and alter them in the presence of fluids that might have existed in the past on Mars. We could analyze the products of those water-rock reactions.”

Hurowitz described Stony Brook as a “spectacular place to grow up in as a student” and called McLennan a “leader” and “pioneer” in his area of research.

So, after all this extra time and information from Opportunity, where does Mars research go from here?

“Mars exploration is at a crossroads,” McLennan suggested. The first scientific priority over the coming decade is to begin the process of bringing samples back from Mars, so geologists like McLennan can study them.

President Obama, however, “cut planetary science and Mars exploration dramatically.”

The House and Congress have tried to reinstate some of the funding in those programs, but “who knows how it’ll end up,” McLennan added. He predicts the next year or so will determine whether scientists and politicians can make progress toward a return to Mars.

In the meantime, McLennan, who lives in Centerport with his wife Fiona, an assistant vice president of Human Resources at Columbia University, will continue to analyze information from the durable Opportunity rover.

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A number of diseases respond favorably such as AMD and rheumatoid arthritis

Last week, I shared the depressing news that omega-3 fatty acids from fish and/or fish oil may not have any positive effects in some diseases, such as heart disease, cancer and multiple sclerosis — a surprise to the medical community. However, omega-3s from these sources may be beneficial in other diseases and disorders, including age-related macular degeneration, dry eye, Alzheimer’s, rheumatoid arthritis, diabetes, anxiety and, ironically, depression. So don’t avoid fish or fish oil yet. Talk to your doctor first. Let’s review some of the studies.

AMD effect

In the Women’s Health Study, there was a significant reduction in risk of developing AMD for those women who ate fish on a regular basis (Arch Ophthalmol. 2011;129(7):921-929). AMD is the leading cause of central vision loss or blindness in patients over 55. The great news is that you don’t have to eat a substantial amount of fish — just one serving per week results in a 42 percent reduction in risk. The fish that had most impact included salmon, mackerel, tuna, bluefish, swordfish and sardines.

I would recommend sardines and salmon, which are lower in mercury than the others and higher in omega-3s. In those who were taking fish oil supplements containing docosahexaenoic acid and eicosapentaenoic acid there were significant, though slightly less robust, reductions in the risk of AMD, 38 percent and 34 percent respectively.

This was a large observational study with 39,000 participants and a mean 10 year follow-up duration. The researchers believe that the mechanism of action may have to do with an anti-inflammatory process, since AMD has underlying inflammation.

AREDS 2 is an ongoing five-year randomized controlled trial, the gold standard of studies, that includes fish oil (clinicaltrials.gov). It will be interesting to see if it reinforces these results.

Alzheimer’s disease
Alzheimer’s disease is neurodegenerative disease. There are no medications yet to reverse or slow its progression, only to treat its symptoms. Thus, it is crucial to find lifestyle modifications that may prevent and treat its effects. In a recent study, consumption of omega-3s from fish showed a significant reduction in beta-amyloid protein, a nonspecific marker of Alzheimer’s disease, as measured in the blood (Neurology online May 2).

In another study, consumption of fish at least one time a week showed preservation of brain volume, tested using MRI scans, in the hippocampus and frontal lobe. These areas are responsible for memory and cognitive function.

Both studies are encouraging for Alzheimer’s disease prevention (RSNA Abstract SST11-04). In yet another study, fish oil seemed to reduce the progression of cognitive impairment in patients with very mild Alzheimer’s disease (Arch Neurol. 2006;63:1402-1408).

Rheumatoid arthritis

In the May 24 article, I wrote about a meta-analysis that showed reduction in joint pain and morning stiffness in those who consumed fish oil (Pain. 2007 May;129(1-2):210-23).
These are two of the most common complaints of patients with rheumatoid arthritis.

Diabetes

Omega-3 fatty acids seem to play a role in prevention of type 2 diabetes. In the Cardiovascular Disease Study, there was a 36 percent reduction in the risk of developing diabetes for those who consumed the most omega-3s (Am J Clin Nutr. 2011;94(2):527-33).
The study was unique in that it tested the levels of DHA and EPA in the blood, a quantitative approach, and determined that participants with the highest levels of these omega-3s were least likely to develop the disease.

This was an observational study with 3,000 participants over a 10-year period. These are encouraging results and may indicate another way to reduce diabetes risk.

Dry eye syndrome

The prevalence of dry eye syndrome increases with age and is a common problem, with a higher prevalence among women (Am J Ophthalmol. 2003;136(2):318-26). In the Women’s Health Study, omega-3 fatty acids reduced the risk of dry eye by 17 percent (Am J Clin Nutr. 2005; 82(4):887-93). The omega-3s may work by blocking pro-inflammatory factors in the eye. The best results were found with tuna: one serving per week reduced risk by 19 percent, while two servings reduced risk by a whopping 68 percent. Interestingly, a high omega-6 (pro-inflammatory) to omega-3 ratio increased the risk of dry eye 2.5 times. The typical American diet is low in omega-3s but very high in omega-6s. Included in this latter category are processed foods; meats — especially red meat; dairy such as cheese, whole milk and butter; and certain processed oils. These are foods that are high in fat, but not good fats.
Omega-3s play a potentially significant role in many diseases, but not in all. There is greater upside for omega-3 fatty acids than downside, except as it relates to prostate cancer risk. However, just as with other substances, it may be better to obtain omega-3s from fish than to rely on fish oil. One thing is sure: We get too many omega-6s and not enough omega-3s in our diet and thus may have a higher propensity toward inflammation, which promotes chronic diseases.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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