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Yearly Archives: 2014

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With spring officially here and — believe or not — beach weather around the corner, millions of American will expose their toes. Some will be more self-conscious about it than others, because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails, but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many patients are bothered by this disorder. Most patients consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1). Onychomycosis is not easy to treat and can be quite uncomfortable.

Onychomycosis affects approximately 8 percent of the population (2). The risk factors are unclear, but may be relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected by it (3).

There are a number of organisms that can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A test commonly used to differentiate the organisms is a KOH (potassium hydroxide) preparation, which is a simple microscopic exam of skin and nail shavings. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of the autoimmune disease psoriasis.

There are a plethora of therapies available for treatment. These range from over-the-counter alternative therapies to prescription topical medications to systemic, or oral, prescription therapies to laser therapies and, finally, surgery. I am regularly asked which treatment works best.

With all of these options, how is one to choose? Well, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. So there is no overnight success. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Fortunately, most cases of nail fungus are benign, with only a fraction leading to infections. Infection is most common in those with diabetic neuropathy, where the patient loses feeling in their feet.

Let’s look at the evidence.

Oral antifungals

There are several options for oral antifungals, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These medications tend to have the greatest success rate, but the disadvantages are their side effects.

In a small but randomized controlled trial, terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of the fungus in their toenails with terbinafine, whereas 21 percent and 32 percent experienced these benefits with fluconazole, depending on the duration. The patients in the terbinafine group were treated with 250 mg of drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of drug for either 12 weeks or 24 weeks, with those in the 24-week group experiencing the better results. Thus, this would imply that terbinafine is the more effective drug. This is a small trial, but the results are intriguing. The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine. Its advantages are the efficacy and the duration.

Another approach to reduce side effects is to give oral antifungals in a pulsed fashion. In a RCT, fluconazole 150 mg or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, the efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, the disadvantages are that it takes approximately a year of daily use, and its efficacy is not as great as the oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In this trial, ciclopirox had to be applied daily for 48 weeks. These results were in patients with mild to moderate levels of fungus in the surface area of the infected nails.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. To make matters worse, many of the laser treatments are not covered by insurance, and they can be expensive. Another research paper that reviewed the current literature concluded that laser therapies are lacking in randomized clinical trials (10).

The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if it is effective.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Additionally, partial improvement occurred in the toenails of 10 patients. But what is more interesting is that all 18 patients rated the results as either “satisfying” or “very satisfying.” The gel was applied daily for 48 weeks. The advantage is low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and the lower efficacy compared to oral antifungals.

So when it comes to onychomycosis, what should one do? None of the treatments are perfect. Oral medications tend to be the most efficacious, but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance. If you decide on this approach, discuss it with your doctor; there are appropriate precautionary tests, such as liver enzyme monitoring with terbinafine (Lamisil), that need to be done on a regular basis. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better initial choice. No matter what you and your physician agree upon as the appropriate treatment, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196;Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Dermatol Online J. 2013 Sep. 14;19:19611. (11) J Am Board Fam Med. 2011;24:69–74.

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 medicalcompassmd.com or consult your personal physician.

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Despite the back pain, foot problems, and other stresses and strains humans feel when walking, we’re pretty good at it. That’s especially true when you compare humans to chimpanzees or other primates.

“Chimpanzees, our closest primate relative, use a lot of energy to walk around,” explained Matthew O’Neill, an instructor in the Anatomical Sciences Department at Stony Brook. “Their cost of walking is 75 percent higher than human walking.”

O’Neill is broadly interested in understanding what role energy use played in human evolutionary history. He believes part of what makes humans unique is the low energy we expend when we walk.

“The energy cost of walking is largely determined by the mechanics of how our pelvis and hind limbs work,” he said. He explores what is different about the way humans walk. If energy were the equivalent of a financial budget, spending less on walking and getting around would allow humans to use those resources in other areas.

“The less we have to use in a given day for locomotion, the more we can allocate to things like maintaining tissue health or on other aspects of living our lives,” O’Neill said.

O’Neill is interested in understanding when and why the human body began to look and work the way it does. Fossils, he said, tell him when humans might have changed the way they walked from our ancestors, while studying humans and chimpanzees may help explain why.

He looks at the forces humans and chimps apply to the ground and the way their limbs move. He uses musculoskeletal models to calculate how bones, muscles and tendons work while walking. He can then try to understand how these different tissues work. One of the areas where he’s collecting data is in how much energy individual muscles consume.

O’Neill’s colleague at Stony Brook, anatomical sciences professor Susan Larson, who has worked with him for five years, called his work “ground-breaking.” For many years, she said, “researchers have been compiling observations characterizing how primates walk, but we didn’t really have much in the way of mechanical explanations for why they display many of these characteristics.”

Larson said O’Neill’s work moves beyond simple descriptive studies to explore “potential underlying mechanical reasons governing their manner of walking.”

O’Neill was recently a collaborator on a broader study on energy use in humans compared with other primates. The main result from that study showed that humans, chimps and other primates use about half as much energy in a 24 hour period as do other mammals, such as mice, antelopes and sea lions. That, O’Neill said, may be information for understanding why primates seem to live longer than other mammals.“There’s simply less wear and tear on our bodies” because of the lower energy lifestyle than other animals have.”

In that study, O’Neill contributed data from research he had done in North Carolina when he was at Duke University on ring-tailed lemurs. There, he had measured daily energy use for these primates, who normally live in Madagascar.

O’Neill is involved in other collaborations as well, including one with Larson, two other Stony Brook faculty members and a researcher from the University of Massachusetts, on a project to develop a computational model of an ape walking on two legs. Once completed, they can use the model to run simulation studies to explore different suggested characteristics of the earliest form of bipedal locomotion, Larson said.

O’Neill is “one of a handful of a new generation of biological anthropologists who are bringing new rigor in the analytical methods applied to studying our own evolution,” Larson added.

O’Neill said he would like to know more about how walking and human walking capabilities evolved. “What I want to do is take information that’s available now and combine it with what we know of living species and get reliable predictions about how a [taxon] might have walked,” he said.

A resident of St. James, O’Neill lives with his wife, Karen Baab, an assistant professor in the Department of Anthropology at Stony Brook, and their infant daughter. The snow has kept them from enjoying rides out on the North Fork, which they hope to resume this spring.

As for looking out at how walking might change in humans, O’Neill, who described his own walk as “slow and lumbering,” said humans don’t need to walk the way we used to, when our “survivorship depended on walking.” As a result, he doesn’t see “a lot changing” in the foreseeable future in the way humans walk.

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By Linda M. Toga, Esq.

The Facts: When I got married in 2000 my wife named me as the beneficiary on her life insurance policy. We were divorced two years ago. Our divorce settlement provides that my ex-spouse is required to continue paying her life insurance premiums and is prohibited from removing me as the beneficiary. I was told that our divorce automatically voids the beneficiary designation on her policy.

The Questions: Is that true? If so, what can I do to protect my right to receive the life insurance proceeds?

The Answer: In 2008 the law in New York changed so that a divorce does sever and/or negate the rights of an ex-spouse to bequests made in a will, appointments made in healthcare proxies and powers of attorney and beneficiary designations made on life insurance policies, to name a few. However, the law provides that the ex-spouse will retain rights and benefits in certain circumstances despite the divorce if there is a controlling document that states as much. If, in fact, your divorce settlement is deemed a controlling document, it is likely that the terms of your settlement will trump the statute. However, unless the insurance company is aware of the term of your divorce, they could very well pay the life insurance benefits to the contingent beneficiary named on your ex-spouses policy or to her estate. To avoid this outcome, you should contact an attorney who can protect your rights and enforce the terms of your divorce settlement.

Linda M. Toga, Esq. provides legal services in the areas of litigation, estate planning and real estate from her East Setauket office.

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What humans, or any other animals, think about the world can be seen in pathways that flash around in the brain, forming connections that inform a view of anything from the smell of steaming hot pizza to directions to a rink for a roller-skating party.

Combining behavioral electrophysiology with quantitative psychophysics and optogenetics, Adam Kepecs, an associate professor at Cold Spring Harbor Laboratory, is specifically looking at how rats report confidence in their decisions.

Looking at the frontal cortex in the brain, Kepecs studies the kinds of neurons that fire as the rat is weighing its options in the face of uncertainty. He likens the process to receiving directions to a restaurant and then following a route until there is no sign of the dining establishment.

“At some point, you will wonder, ‘Is the restaurant coming up or should I turn around?’” he said. “Presumably, the more confident you are, the longer you will keep driving. That’s exactly what we can do with rats. We can repeat [this experiment] hundreds of times a day by manipulating the instructions.”

To further the restaurant search analogy, that would be the equivalent of receiving instructions that were slightly garbled through a cell phone or where foliage obscured a sign a driver was expecting to see.
The directions the rat receives, Kepecs said, come from olfactory or auditory cues rather than visual ones. “We’re testing how you could turn this initial confidence into a choice,” he said. “We want to see how long do [they] wait.”

The analysis of the data he and his team of eight people collect comes from comparing a statistical evaluation of neurons that are within tens of microns of each other and the decisions that come from a rat that is faced with a choice about staying the course.

“This is a great statistical evaluation of how likely a decision was correct,” Kepecs said. Kepecs said these kinds of experiments enable him to study basic behaviors that get to the heart of how the rats process information and weigh that against what’s happening around them. “We’re trying to ask a big psychological question and we need to reduce it to an elemental behavior and turn it into something we can study as neuroscientists,” he said.

While Kepecs isn’t yet ready to extend his research to humans, he said the implications and applications of this research could include helping people who struggle with problems such as obsessive compulsive disorder. “If you lose confidence about your actions, you might repeat them,” he said. “This is the kind of thing [his research] is moving towards.”

Kepecs’ colleagues appreciate his approach to his research. “He is an outstanding scientist,” said Anthony Zador, the program chair of neuroscience at CSHL. He has a “well-earned reputation for being creative and innovative.”

In a separate line of experiments, Kepecs is also working with a region deep within the brain, called the nucleus basalis. Degeneration in this area has been linked to Alzheimer’s disease, Parkinson’s dementia and age-related cognitive declines.

Indeed, Kepecs recently received the 2014 Memory and Cognitive Disorders Award from the McKnight Endowment Fund for Neuroscience, which provides $100,000 a year for three years. The award supports research designed to solve problems of neurological and psychiatric diseases, with an emphasis on those that affect cognition and memory.

“This area has been a puzzle,” said Kepecs. “It’s made up of many cell types. Until now, there was no way of recording identified cells. What we’re trying to do is record from identified cholinergic neurons, to figure out what they’re telling the rest of the brain.”

Kepecs studied computer science in his native Budapest, Hungary. He was fascinated with the way the mind works. “I have a deep interest in the mind and computer science was my route,” he explained. A resident of Huntington, Kepecs is married with two children.

Kepecs said he is excited to take the next steps in linking activity in neural circuits to confidence. “How can you study anything that’s internal to your brain?” he asked. That is what his experiments on neurons and behavior are designed to examine.

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Most of us know that type 2 diabetes is an epidemic in America and continues to grow. Type 2 diabetes was thought to be an adult-onset disease, but more and more children and adolescents are affected as well. The most recent statistics show that 50% of teens with diabetes between the ages of 15 and 19 have type 2 (1). Thus, this disease is pervasive throughout the population.

Let’s test our diabetes IQ. See if you can determine if the following are true or false. Don’t worry, you won’t be judged or graded for wrong answers; this is meant to encourage you to learn more.

1) Whole fruit should be limited or avoided.

2) Soy has detrimental effects with diabetes.

3) Plant fiber provides too many carbohydrates.

4) Coffee consumption contributes to diabetes.

5) Bariatric surgery is an alternative to lifestyle changes.

My goal is to help debunk type 2 diabetes myths. All of these statements are false.

Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has always been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Recent studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (2).  In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (3).

In yet another study, researchers looked at different whole fruits to determine their impacts on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (4). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe. To read more detail about some of these studies, please see my article, “Sugar, Sugar.” Fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

We know fiber is important in a host of diseases, and it is not any different in diabetes. In the Nurses’ Health Study and NHS II, two very large prospective (forward-looking) observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (5). Researchers looked at lignans, a type of plant fiber, specifically examining metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors therefore encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include: flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (6). The researchers could not determine which plants contributed the most benefit. They believe the effect is from antioxidant activity.

Soy and kidney function

Soy sometimes has a negative association. However, in diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (7). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better. This was a small but randomized controlled trial, considered the gold standard of studies, over a four-year period with 41 participants. The control group’s diet consisted of 70% animal protein and 30% vegetable protein, while the treatment group’s consisted of 35% animal protein, 35% textured soy protein and 30% vegetable protein. This is very important since diabetes patient are 20-to-40 times more likely to develop nephropathy than those without diabetes (8). It appears that soy protein puts substantially less stress on the kidneys than animal protein, which creates nitrogenous waste products. However, those who have hypothyroidism should avoid soy.

Coffee

Coffee is a staple in America and in my household. It is one thing my wife would never let me consider taking away. Well she and the rest of the coffee-drinking portion of the country can breathe a big sigh of relief when it comes to diabetes. There is a new meta-analysis (involving 28 prospective studies) that shows coffee decreases the risk of developing diabetes (9). It was a dose-dependent effect; two cups decreased the risk more than one cup. Interestingly, it did not matter whether it contained caffeine or was decaffeinated. This suggests that caffeine is not necessarily the driving force behind the effect of coffee on diabetes. The authors surmise that other compounds, including lignans, which have antioxidant effects, may play an important role. The duration of the studies ranged from 10 months to 20 years, and the database was searched from 1966 to 2013, with over one million participants.

Bariatric Surgery

In the last few years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m2) and obese (BMI >30 kg/m2) diabetes patients. In a meta-analysis of bariatric surgery (involving 16 RCTs and observational studies), the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (10). During this time period, 72% of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss. However, after 10 years without proper management involving lifestyle changes, only 36% remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintain long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home messages are: don’t avoid whole fruit; soy is potentially valuable; fiber from plants may play a very powerful role in preventing and treating diabetes; and coffee may help prevent diabetes. Thus, the overarching theme is that you can’t necessarily go wrong with a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to increase the likely durability over 10 or more years.

References:

(1) JAMA. 2007;297:2716-2724. (2) Nutr J. 2013 Mar. 5;12:29. (3) Am J Clin Nutr. 2012 Apr.;95:925-933. (4) BMJ online 2013 Aug. 29. (5) Diabetes Care. online 2014 Feb. 18. (6) Br J Nutr. 2005;93:393–402. (7) Diabetes Care. 2008;31:648-654. (8) N Engl J Med. 1993;328:1676–1685. (9) Diabetes Care. 2014;37:569-586. (10) Obes Surg. 2014;24:437-455.

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 medicalcompassmd.com or consult your personal physician.

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His previous passport had close to 100 extra pages. His current passport, which he started using in 2010, may well exceed that. “My passport is a source of never-ending amusement for my friends,” said Russell Mittermeier, an adjunct professor at Stony Brook.

What drives the 64-year-old scientist to travel to places like Brazil, Madagascar and Suriname is the need to monitor the health of ecosystems where rare, threatened or endangered animals, including many non-human primates, live.

Mittermeier, who is the president and one of the leaders of Conservation International, encourages local communities to rally around the animals that live in their areas, meets with the leaders of national governments, and seeks donors who will support efforts to preserve hot spots — important regions where the density of threatened species is high. At these hot spots, 2.3 percent of Earth’s land surface contains more than half of all plant species and over 40 percent of all vertebrates, he said.

He helps develop “primate ecotourism, which is based on the model of bird-watching, to help get more people to see primates and get excited about them,” Mittermeier said. Ecotourism generates revenue for the communities living close to priority areas for primates, he explained. “Species are not evenly distributed across the planet,” Mittermeier said from an airport in Miami on his way to Suriname. “They are heavily concentrated in some areas. Many of those areas are severely impacted by human activities.”

Conservation International Funds, including the Critical Ecosystem Partnership Fund and the Global Conservation Fund “have been instrumental in funding conservation in these hot spots,” he said.

Mittermeier’s research and conservation efforts recently earned him a second nomination as a finalist for the Indianapolis Prize, a highly prestigious award given every two years to someone who contributed to conservation of a species or species. The winner receives a $250,000 cash award. Mittermeier said he is honored to be a finalist and called the award “the premier prize in wildlife conservation.”

Patricia Wright, a professor in the Anthropology Department at Stony Brook, said Mittermeier “has a reputation of being a conservation leader, putting together the big picture on conservation policy.”

Wright said the books “Lemurs of Madagascar” (2010) and last year’s “Handbook of the Mammals of the World,” in which Mittermeier was the lead editor, are a “life’s work in themselves. These field guides and references are treasures for spurring conservation awareness.”

Mittermeier’s career has taken him to places where he has been the first to see or recognize a new species of animal.

In 1974, as a graduate student at Harvard, Mittermeier was in the Northern Peruvian Andes, looking for a yellow-tailed woolly monkey when he found a small brown frog. A few days later, he collected a lizard.

About 15 years later, an expert in frogs studied some of the individual brown frogs Mittermeier had brought back with him and determined it was an unknown species. He named it after Mittermeier. Some time later, the lizard he found from that trip took his name, too. Mittermeier has had seven species, including two lemurs and an ant, named after him, while he has been the first to describe 14 species.

On his journeys around the world, Mittermeier has created some amusing, and hair-raising, memories. He has come face-to-face with tigers and jaguars. In 2010, Mittermeier was on a trip in Suriname with his two sons, John, now 28, and Mickey, now 21. He was traveling with the U.S. ambassador to that country, John Nay. On the way back from climbing a mountain, their boat turned over. The group lost sight of Nay, who was wearing a life vest, for a few moments.

“About 200 meters over, he had floated to another pile of rocks,” Mittermeier recalled. “He had a great story to tell” after his return.

Mittermeier’s children have followed in his world-traveling footsteps. An ornithologist, John, who saw over 2,000 bird species in the past year, is working towards his doctorate at Louisiana State University. A junior at Eckerd College in St. Petersburg, Fla, Mickey is doing a term abroad in Australia, where he studies reptiles and is also interested in anthropology. His daughter Juliana is a senior in high school.

Mittermeier has no intention of slowing down in his conservation efforts and remains optimistic about his work. He said he “wont be stopped by anything.” He either “runs over an obstacle or moves around it.” His passport is proof of that.

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Stephen Nash’s world is populated by the bushiness of eyebrows, the length of tails, and the exact color of skin or fur. An award-winning illustrator, Nash has spent over 30 years at Stony Brook, where he has honed his craft of creating artistic renderings of gibbons, monkeys, apes, gorillas, and numerous others.

British-born and trained, Nash, who is a visiting research associate in the Department of Anatomical Sciences at Stony Brook, came to Long Island in 1982 at the request of Russell Mittermeier, the president of Conservation International. The combination has become a force in conservation, raising awareness of, and potential threats to, numerous primates, as well as other species, such as tree kangaroos in Papua, New Guinea and baobab trees in Madagascar.

Nash provided illustrations, compiled over the course of his career, for a book published last spring called “Mammals of the World: Primates.” At 10.5 pounds, the hard-cover book, which Mittermeier and others edited, is equal to the weight of about 67 mouse lemurs.

Animals are often not cooperative when it comes to posing for pictures, especially when a scientist would like to take a photo that reflects something unique about its physical appearance.

Illustrators like Nash, whose wife Lucille Betti-Nash shares the same profession and works at Stony Brook, use a combination of photos and videos, descriptions from available literature and discussions with current scientists to create images that most closely resemble animals that sometimes rely on staying away from human, and other mammalian, eyes to survive.

He starts by sending an email sketch to scientists all around the world. These researchers appreciate the attention Nash pays to details to make sure he creates an image that illustrates the unique differences among species.

“His care in the posing and portrayal of nonhuman primates communicates the beauty and splendor” of these animals, explained Jeffrey French, a psychology professor at the University of Nebraska, Omaha. French said Nash’s work is “unexcelled by anyone else in the business,” and scientists and conservationists “value the opportunity to have [him] produce artwork for their books, articles and press releases.”

Nash said his job is to be a “servant of science.” If, for example, one gibbon species looks different from another by the bushiness of its eyebrows, he will “do my best to produce illustrations of that.”

Technology has enabled the process to become more efficient. In the earlier days, after he graduated from the Royal College of Art in London, where he studied natural history illustration, he might have started with a preliminary version of a gorilla that needed a longer neck or a darker back. “That might have required starting a new drawing,” he said. “Nowadays, I can make changes and send back a new version, virtually within minutes.”

Nash said he loves working with colored pencils. He appreciates how he can buy colored pencils that have hundreds of colors, although he still finds he has to apply some color alchemy to create an exact visual match. He wets a paintbrush and brushes over the pencil strokes, uniting the colors.

“All sorts of special structures in nature — the iridescence of a butterfly’s wing or the special shine on a snake’s scale — might require special blending or a special treatment,” he said.

Nash has a favorite primate: the cotton-top tamarin, which was one of the first he drew. The matamata turtle is his favorite animal, while the fern is his favorite plant, and Darwin’s frog is his favorite reptile.

“Everyone should have these favorite natural phenomena,” he suggested. “Ideally, you get involved and you find out all you can about them.”

Residents of Stony Brook, Nash and his wife have a few of their illustrations on the walls of their home. They also have images of primates from the 1800s and early 1900s on their walls. The couple has dug ponds and planted native plants to maximize biodiversity in their backyard.

Nash’s wife, a birdwatcher who gets up at 4 am each year as a part of the Christmas Bird Count, has seen more than 100 bird species in their yard. “Our house and garden is an expression of us,” he said.

The couple hasn’t done illustrations of each other. While that might be something they’d consider if and when they retire, Nash doesn’t expect to slow down any time soon, especially since his longtime colleague Mittermeier remains active. “While [Mittermeier] is working, he’ll be doing wonderful things I want to illustrate.”

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Certain kinds of fruit may reduce the risk of diabetes

We should all reduce the amount of added sugar we consume, because of its negative effects on our health. It is recommended that we get no more than 5 to 15 percent of our diet from added sugars and solid fats, combined. (1) However, approximately 13 percent of our diet is from added sugars alone. (2)

Is all sugar bad for us? The answer is not straightforward. It really depends on the source, and when I mention source, my meaning may surprise you.

We know that white, processed sugar is bad. But, I am constantly asked which sugar source is better: honey, agave, raw sugar, brown sugar or maple syrup? None are really good for us; they all raise the level of glucose (a type of sugar) in our blood. Two-thirds of our sugar intake comes from processed food, while one-third comes from sweetened beverages, according to the most recent report from the CDC. (2) Sweetened beverages are defined as sodas, sports drinks, energy drinks and fruit juices. That’s right: even 100 percent fruit juice can raise our glucose levels. Don’t be deceived because it says it’s natural and doesn’t include “added” sugar.

These sugars increase the risk of, and may exacerbate, chronic diseases, such as diabetes, heart disease, high blood pressure, cancer and obesity. This is such a significant problem that California’s legislature is considering adding warning labels to sweetened drinks. (3) The label would indicate that added sugars can increase the risk of diabetes and obesity, as well as tooth decay.

However, I did say that sugar’s source impacts its effect. Most fruits have beneficial effects in preventing disease, including diabetes, and do not raise sugar levels, even in patients with diabetes. It is a myth that whole fruit raises your sugar levels. However, dried fruits, fruit juice, and fruit concentrate do raise your sugar levels. Note that sugar extracted from fruit has an effect similar to that of sugar added to foods and sweetened beverages. Let’s look at the evidence.

Heart disease

When we think of sugar’s effects, heart disease is not usually the first disease that comes to mind.

However, results from a 20-year study of 31,000 U.S. adults showed that, when comparing those who consumed the least amount of added sugar (less than 10% of calories daily), with those who consumed 10-25% and those who consumed more than 25% of daily calories from sugar, there were significant increases in risk of death from heart disease, 30% and a 275%, respectively (4). The added sugar was from foods and sweetened beverages, not from fruit and fruit juices.

This was not just an increased risk of heart disease, but an increased risk of cardiovascular death. This is a wake-up call to rein in our sugar consumption.

Obesity and weight gain

Does soda increase obesity risk? A recent assessment published in PLoS One, a highly respected, peer-reviewed journal, showed that it depends whether studies were funded by the beverage industry or had no ties to any lobbying groups.(5) Study results were mirror images of each other: studies not affiliated with the industry show that soda may increase obesity risk, while studies funded by the beverage industry show there may not be any association.

In studies without beverage industry funding, greater than 80 percent (10 of 12) showed associations between sugary drinks and increased weight or obesity, whereas with the beverage industry-funded studies, greater than 80 percent of them did not show this result (5 of 6). The moral of the story is that patients must be diligent in understanding studies’ funding, and if the results sound odd, they probably are. If this is the case, make sure to ask your doctor about the studies’ findings. Not all studies are equally well-designed.

Diabetes and the benefits of fruit

Diabetes requires the patient to limit or avoid fruit altogether, correct? This may not be true. Several recent studies may help change the long-standing, commonly held paradigm that fruit should be restricted in patients with diabetes and to prevent development of diabetes.

One study found that whole fruit may reduce the risk of diabetes by reducing inflammation and reducing insulin resistance. (6) Specifically, results demonstrated a reduction in the inflammatory biomarker hsCRP. Ultimately, this may result in better glucose control. A potential reason for these impressive results may be the high levels of flavonoids, specifically anthocyanins and flavones. Flavonoids, as a class, are phytochemicals (plant nutrients) that provide pigment to fruits and vegetables and may have substantial antioxidant activities. Substances that are high in these two flavonoids include red grapes, berries, tea and wine.

Another study, a meta-analysis that looked at three large studies, including the Nurses’ Health Study, NHS II, and the Health Professionals Follow-up Study, showed that those who consumed the highest amount of anthocyanins were likely to experience a 15 percent reduction in the development of type 2 diabetes. (7) Researchers compared those in the highest quintile of anthocyanin consumption with those in the lowest quintile.

Specifically, at least two servings of blueberries per week were shown to reduce the risk of diabetes by 23 percent, and at least five servings of apples and pears per week were also shown to reduce the risk by 23 percent. These were compared to those who consumed less than one serving per month. This is a small amount of fruit for a significant reduction.

From the same three studies, it was also shown that grapes, bananas and grapefruit reduce the risk of diabetes, while fruit juice and cantaloupe may increase risk. (8)

In still another diabetes study, involving those who were newly diagnosed with type 2 diabetes, the risk of increasing glucose levels was no greater in those who consumed more than two servings of fruit per day compared to those who consumed fewer than two servings per day. (9) For more details on this study, please review my March 14, 2013, article, “Diabetes: looking beyond obesity to other factors.”

The properties of flavonoids, for example found in whole fruit, may also result in anticancer and anticardiovascular disease properties, the opposite of added sugars. (10)

Chronic disease incidence and complications from these diseases have skyrocketed in the last several decades. Therefore, any modifiable risk factor should be utilized to decrease our risk. By keeping added sugar to a minimum in our diets, we could make great strides in the fight to maintain our quality of life as we age.

We don’t have to avoid sugar completely; we still can satiate a sweet tooth by eating ripe fruits. Our access to fruit, even off-season, has expanded considerably. The most amazing thing is that fruit may actually reduce the risk of diabetes, something for years we thought might exacerbate it.

References: (1) 2010 Dietary Guidelines for Americans. (2) cdc.gov. (3) reuters.com. (4) JAMA Intern Med. online February 03, 2014. (5) PLoS Med. 2013 Dec;10(12):e1001578. (6) J Nutr. 2014 Feb;144(2):202-8. (7) Am J Clin Nutr. 2012 Apr;95(4):925-33. (8) BMJ. online August 29, 2013. (9) Nutr J. published online March 5, 2013. (10) Plant Foods Hum Nutr. 2004 Summer;59(3):113-22.

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 medicalcompassmd.com or consult your personal physician.

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Stony Brook doesn’t just use bacteria, viruses, and DNA in its research. The university also seeks human volunteers, for studies in areas ranging from cancer and HIV to sociology.

Currently, the university has about 1,000 active projects that involve volunteers, including a study on obese individuals who are insulin-resistant and are prone to developing type 2 diabetes.

The human subjects are people, not data, and “without them, we don’t have advances in medicine at this campus,” said Judy Matuk, the assistant vice president for research compliance at Stony Brook. “There’s a big respect issue on this campus.”

Indeed, for 26 years, Matuk has been in charge of human subject compliance, assuring that the process of including people in studies meets various standards and includes informed participants. “We want to have the community know research goes on,” she said. Her office also wants to make sure “folks are aware of their rights.”

Matuk said humans don’t waive any right as test subjects. She also emphasized that the consent process requires scientists to spell out exactly what’s involved in each experiment.

“At the end of a discussion” about the research, “if the potential subject says, ‘What do you think I should do?’ then that process failed. The process should have all the information they need to make a decision on their own.”

When she speaks to researchers who are planning to use humans in their studies, she emphasizes that each person is “somebody’s somebody” whether that’s an aunt, a mother, a sister, or a brother. She wants to make sure people aren’t data points, the way temperature and humidity readings might be for someone studying the weather.

Stony Brook is well aware of research horror stories. One of the most famous was the Tuskegee syphilis experiment, in which the U.S. Public Health Service studied syphilis in African-American men between 1932 and 1972. During the study, people who had syphilis did not receive treatment that had become available during that time.

After that study, the National Research Act passed, Matuk said, which established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. This group, which met in the Belmont Conference Center of the Smithsonian Institute, created a code, called the Belmont Report, that outlined a set of ethical principles that guides research involving human subjects.

The research review process in place at Stony Brook meets and exceeds federal requirements by using best practices. Colleagues at Stony Brook consider Matuk “tough but fair,” said Harold Carlson, a professor of medicine and chairman of one of the two institutional review boards at Stony Brook.

Carlson, who has known Matuk for 26 years, described her as an “extremely effective” leader, as an educator of the faculty and an enforcer of the rules and regulations with human subjects in research.

Researchers, who receive approval for a maximum of one year, are required to notify a review board if something unanticipated happens. With all the safeguards in place, Matuk said she is proud of the contributions Stony Brook has made to research fields. That includes work with drug trials on the human immunodeficiency virus.

At the same time, Matuk wants anyone participating in these studies, especially of drugs that might help treat a chronic condition or illness, to understand that “this is not clinical care. This is research. We don’t know the answer” about whether the treatment will prove more effective than the current standard of care.
Members of the Long Island community can help out with research, even if they don’t have a chronic condition.

A resident of Miller Place, Matuk lives with her husband, Jay Matuk, the principal of Cold Spring Harbor Junior/Senior High School. The couple have three children: Katie, 27, Zachary, 22 and Paige, 18.
Aside from family, Matuk said she is an active member of her temple, Beth Emeth in Mount Sinai, where she was president for five and a half years.

“When you talk about people volunteering, you always think the next guy will do it,” she said. ‘That’s a dangerous attitude to have. You want to know you can make a difference.”

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By Linda M. Toga, Esq.

The Facts: My mother recently died. In her Will she left her entire estate to me. If I had died before my mother, her estate would have passed to my children in equal shares. I would like my inheritance from my mother to pass to my children.

The Question: Is there a way I can accomplish that? If so, what is involved?

The Answer: You can certainly arrange for your inheritance under your mother’s Will to pass directly to your children by renouncing or disclaiming your interest in your mother’s estate. To do so you must use a qualified disclaimer.

How it Works: A qualified disclaimer is a writing in which you identify the assets you do not wish to receive. In this case, you would indicate that you are renouncing your interest in all assets passing under your mother’s Will. The disclaimer does not have any effect on assets such as jointly held property in which your mother may have had an interest or assets that pass according to a beneficiary designation form such as IRAs and life insurance.

The disclaimer must be delivered to the executor of the estate and filed with the surrogate’s court that issued letters testamentary to the executor.

Since your mother’s Will names your children as the contingent beneficiaries in the event you predeceased her, disclaiming your interest in her estate will result in her entire probate estate passing directly to your children. However, if other contingent beneficiaries had been named, your share of the estate would pass to the individuals named in the Will and not your children. That is because a beneficiary who renounces their interest in an estate cannot choose who will receive the disclaimed probate assets. This is true not only when there is a Will, but also when a person who is in line to inherit from an estate where the decedent died without a Will wishes to renounce that inheritance. Where there is no Will, the intestacy statute which dictates which family members are entitled to a share of an estate will govern how assets in the estate are distributed if someone renounces.

Beyond disclaiming your inheritance, there are other strategies that may be used to accomplish your stated goal of having your children receive the assets in your mother’s estate. As with all estate issues, it is important to consult with an attorney with experience in estate administration before filing a disclaimer to make sure the filing will not result in any unintended consequences.

Linda M. Toga, Esq. provides legal services in the areas of litigation, estate planning and real estate from her East Setauket office.

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