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David McCandlish, center, with postdoctoral researchers Anna Posfai and Juannan Zhou. Photo by Gina Motisi, 2020/ CSHL

By Daniel Dunaief

If cancer were simple, scientists would have solved the riddle and moved on to other challenges.

Often, each type of the disease involves a combination of changes that, taken together, not only lead to the progression of cancer, but also to the potential resistance to specific types of treatment.

Using math, David McCandlish, Assistant Professor at Cold Spring Harbor Laboratory, is studying how the combination of various disruptions to the genome contribute to the development of cancer.

McCandlish recently published a study with colleagues at Cold Spring Harbor Laboratory in the journal Proceedings of the National Academy of Sciences.

David McCandlish. Photo by Gina Motisi, 2020/CSHL

The research didn’t explore any single type of cancer, but, rather applied the method looking for patterns across a range of types of cancers. The notion of understanding the way these genetic alterations affect cancer is a “key motivating idea behind this work,” McCandlish said.

So far, the method has identified several candidates that need further work to confirm.

“Cancer would be a lot easier to treat if it was just one gene,” said Justin Kinney, Associate Professor at CSHL and a collaborator on the work. “It’s the combination that makes it so hard to understand.”

Ultimately, this kind of research could lead researchers and, eventually, health care professionals, to search for genetic biomarkers that indicate the likely effect of the cancer on the body. This disease playbook could help doctors anticipate and head off the next moves with various types of treatments.

“This could potentially lead to a more fundamental understanding of what makes cancer progress and that understanding would very likely open up new possibilities in cancer treatments,” Kinney said.

To be sure, at this point, the approach thus far informs basic research, which, in future years, could lead to clinical improvements.

“We are working on this method, which is very general and applicable to many different types of data,” McCandlish said. “Applications to making decisions about patients are really down the road.”

McCandlish described how he is trying to map out the space that cancer evolves in by understanding the shape of that space and integrating that with other information, such as drug susceptibility or survival time.

“We are trying to ask: how do these variables behave in different regions of this space of possibilities?” he said.

McCandlish is making this approach available to scientists in a range of fields, from those scientists interpreting and understanding the effects of mutations on the development of cancer to those researchers pursuing a more basic appreciation of how such changes affect the development and functioning of proteins.

“This is accessible to a wide array of biologists who are interested in genetics and, specifically in genetic interactions,” said McCandlish.

The main advance in this research is to take a framework called maximum entropy estimation  and improve its flexibility by using math to capture more of the underlying biological principals at work. Maximum entropy estimation is based on the idea of inferring the most uniform distribution of behaviors or outcomes with the least information that’s compatible with specific aspects of experimental observations.

Using this philosophy, scientists can derive familiar probability distributions like the bell curve and the exponential distribution. By relaxing these estimates, scientists can infer more complicated shapes.

This more subtle approach enhances the predictive value, which captures the distributions of data better, McCandlish explained. “We’re trying to capture and model cancer progression in a new and more expressive way that we hope will be able to tell us more about the underlying biology.”

The idea for this paper started when McCandlish, Kinney and  Jason Sheltzer, a former fellow at Cold Spring Harbor Laboratory and a current Assistant Professor of Surgery at Yale School of Medicine, discussed the possibilities after McCandlish attended a talk by Wei-Chia Chen, a post doctoral researcher in Kinney’s lab.

Chen will continue to pursue questions related to this effort when he starts a faculty position in the physics department at National Chung Cheng University in Taiwan this spring.

Chen will use artificial intelligence to handle higher dimensional data sets, which will allow him “to implement effective approximations” of the effect of specific combinations of genetic alterations, Kinney said.

Kinney believes teamwork made this new approach, which the high-impact, high-profile journal PNAS published, possible.

“This problem was an absolutely collaborative work that none of us individually could have done,” Kinney said. He described the work as having a “new exploratory impact” that provides a way of looking at the combination of genomic changes that “we haven’t had before.”

Working at Cold Spring Harbor Laboratory, which McCandlish has done since 2017, enables collaborations across different disciplines.

“We have this quantitative biology group, we also have people working on neuroscience, cancer, and plant biology,” McCandlish added.

McCandlish is also currently also working with Professor Zachary Lippman and his graduate student Lyndsey Aguirre to understand how multiple mutations interact to influence how the fruit on tomato plants develop.

“The idea is that there are these huge spaces of genetic possibilities where you can combine different mutations in different ways,” McCandlish explained. “We want to find those key places in that space where there’s a tipping point or a fork in the road. We want to be able to identify those places to follow up or to ask what’s special about this set of mutations that makes it such a critical decision point.”

A native of Highland Park, New Jersey, McCandlish was interested in math and science during his formative years. 

As for the work, McCandlish appreciates how it developed from the way these collative researchers interacted.

“This would never have happened if we weren’t going to each other’s talks,” he said.

David Thanassi. Photo by Jeanne Neville
*Please note: This article was updated on Oct. 15 to include a reference to former President Bill Clinton (D) in the fifth paragraph.

By Daniel Dunaief

David Thanassi wants to give dangerous bacteria in the kidney a haircut.

No, not exactly, but Thanassi, Zhang Family Professor and Chair of the Department of Microbiology and Immunology at the Renaissance School of Medicine at Stony Brook University, has studied how hair-like structures called P pili in the bacteria Escherichia coli are assembled on the bacterial surface. 

These pili allow bacteria to hang on to the walls of the kidney, where urine would otherwise flush them out.

Learning about pili at different stages of development could provide a way to keep them from attaching themselves to the kidney and from entering the bloodstream, which could lead to the potentially lethal problem of bacterial sepsis. Indeed, this week, former President Bill Clinton (D) checked into the intensive care unit at the University of California Irvine Medical Center after a urinary tract infection spread to his bloodstream.

“We have been looking at this as a really important aspect of initiating infection from a bacteria’s point of view,” Thanassi said. “How do they build these structures” that lead to infection and illness?

Recently, Thanassi published the structure of these pili in the journal Nature Communication.

The current work builds on previous efforts from Thanassi to determine the structure of these pili in the bladder. He has been exploring how the thousands of proteins that make up the pili get transported and assembled in the correct order. “If we can understand that aspect, we can disrupt their assembly or function,” he said.

Urinary tract infections are a major infectious disease, particularly for women. Indeed, about half of all women will have at least one urinary tract infection, which can be uncomfortable and can require some form of medication. 

In some cases, the infections can be recurrent, leading to frequent infections and the repeated need for antibiotics.

The bacteria that cause these infections can become resistant to antibiotics, increasing the importance of finding alternative approaches to these infections, such as interfering with pili.

To be sure, the solution to reducing the bacteria’s ability to colonize the kidney or urinary tract would likely require other steps, as these invaders have additional ways beyond the pili to colonize these organs. Nonetheless, disrupting the way they adhere to the kidney could be a constructive advance that could lead to improved infection prevention and treatment.

One likely strategy could involve using an anti-pilus treatment in combination with other antibiotics, Thanassi explained.

For people who have recurrent infections, anti-pilus therapeutics could offer a solution without resorting to long-term antibiotics.

In his lab, Thanassi is interested in small molecules or chemicals that would disrupt the early stage in pili assembly. “We think of these as protein-protein interactions that are required to build these” pili, he said.

By using a fluorescence reporter, Thanassi and his colleagues can screen libraries of chemicals to determine what might inhibit the process.

As with many biological systems, numerous compounds may seem appropriate for the job, but might not work, as medicine often requires a specific molecule that functions within the context of the dynamic of a living system.

For the helpful bacteria in the gut, pili are not as important as they are for the harmful ones in the kidney, which could mean that an approach that blocked the formation of these structures may not have the same intestinal and stomach side effects as some antibiotics.

To determine the way these pili develop structurally, Thanassi and his lab used molecular and biochemical techniques to stop the assembly of pili at specific stages.

Bacteria assemble these pili during the course of about 30 minutes. An usher proteins serves as the pilus assembly site and pilus secretion channel in the bacterial outer membrane. The usher acts as a nanomachine, putting the pilus proteins into their proper order. A chaperone protein brings the pilus subunits to the usher protein.

In their development, the pili require a protein channel, which is an assembly site.

Thanassi started by working on the usher protein in isolation. The usher proteins function to assemble the thousands of pilus subunits that make up each pilus fiber. The process also involves chaperone proteins, which bind to nascent subunit proteins and help the subunits fold. The chaperone then delivers the subunit proteins to the usher for assembly into the pilus fiber. He used molecular and biochemical methods to express and purify the usher protein.

The assembly process involves interactions between chaperone-subunit complexes and the usher. Over the years, Thanassi has determined how the different proteins work together to build and secrete a pilus.

He was able to force the bacteria to express only one version of the assembly step and then isolate that developmental process.

The majority of the pilus is like a spring or a coil, which can stretch and become longer and straighter to act as a shock absorber, allowing the bacteria to grab on to the kidney cells rather than breaking.

Other researchers are studying how they might make the pili more brittle, preventing that spring-like action from working and compromising its ability to function.

“We’re trying to prevent the pili from assembling in the first place,” Thanassi explained. “Our approach is to try and get molecules that prevent the interaction from occurring.” He is looking at the specific function of one molecule that prevents the usher assembly platform from developing properly, which would wipe out the assembly site.

Thanassi credits former Stony Brook Professor Huilin Li, who is now Chair in the Department of Structural Biology at the Van Andel Institute in Grand Rapids, Michigan, with providing structural insights from his work with the cryo-electron microscoipe. The technology has “revolutionized the work we do,” said Thanassi.

Residents of Smithtown, Thanassi and his wife Kate Kaming, who is Senior Director of Cancer Development at Northwell Health Foundation, have two children. Joseph, 22, attends Northeastern University. Miles, 20, is studying at the Massachusetts Institute of Technology.

Thanassi grew up in South Burlington, Vermont and is an avid skier. He also enjoys mountain biking, walking and music.

Thanassi hopes this latest structural work may one day offer help either with the prevention of infections or with their treatment.

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

By David Dunaief, M.D.

Dr. David Dunaief

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

What are the baseline risks for heart disease?

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

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

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

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

Does medication lower heart disease risk?

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

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

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

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

Do lifestyle changes really reduce heart disease risk?

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

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

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

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

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

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

References:

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

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

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Focus less on balancing protein, carbohydrates and fats

By David Dunaeif, M.D.

Dr. David Dunaief

The road to weight loss, or even weight maintenance, is complex. There are many things that influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

Knowing a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or can actually encourage higher calorie purchases (1, 2). The good news is that controlling weight isn’t solely about exercising willpower. Instead, we need to change our diet composition.

In my clinical experience, increasing food quality has a tremendous impact. Focusing on foods that are the most micronutrient dense tends to be the most satisfying, rather than focusing on foods’ macronutrient density, such as protein, carbohydrates and fats. In a week to a few months of emphasizing micronutrients, one of the first things patients notice is a significant reduction in cravings.

Are refined carbohydrates bad for you?

Generally, we know that refined carbohydrates don’t help. Looking deeper, a small, randomized control trial (RCT) showed refined carbohydrates actually may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown with MRI scans of trial subjects.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were unaware of which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number of calories consumed. Commonly found high-glycemic foods include items like white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates.

What’s the right balance of protein, carbohydrates and fats?

We tend to focus on macronutrients — protein, carbohydrates, and fats — when we look at diets. Which has the greatest impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among study groups, nor was there much success in helping obese patients reduce their weight (4, 5). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Focusing primarily on macronutrient levels and calorie counts did very little to improve results.

What’s the relationship between           micronutrients and weight?

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be micronutrient-deficient (6). Micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements doesn’t solve the problem; generally, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation, by increasing the variety of foods in your diet. Please ask your doctor.

Long-term benefits of reducing              cortisol levels

Cortisol raises blood-levels of glucose and is involved in promoting visceral or intra-abdominal fat. This type of fat can coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality.

The good news is that once people lose weight, it may be easier to continue to keep weight off. In a prospective (forward-looking) study, results show that once obese patients lost weight, the levels of cortisol metabolite excretion decreased significantly (7). This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about calorie-counting. While calorie intake has a role, food’s nutrient density may be more important to your success and may play a significant role in reducing your cravings, ultimately helping you manage your weight.

References:

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) Am J Clin Nutr Online 2013;Jun 26. (4) N Engl J Med 2009 Feb 26;360:859. (5) N Engl J Med 2009 Feb 26;360:923. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

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

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Antibiotic use can affect the microbiome

By David Dunaief, M.D.

Dr. David Dunaief

Each of us has a microbiome — trillions of microbes that include bacteria, viruses and single-cell eukaryotes that influence our body’s functions. When “good” and “bad” microbes are in balance, we operate without problems. However, when the balance is tipped, often by environmental factors, such as diet, infectious diseases, and antibiotic use, it makes us more susceptible to diseases and disorders.

While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where most of our microbiome lives.

Research into the specifics of our microbiome’s role in healthy functioning is still in its infancy. Current research into the microbiome’s effects include its role in obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

What influences our microbiome?

Lifestyle, such as diet, can impact our microbiome positively or negatively. Microbiome diversity may be significantly different in distinct geographic locations throughout the world, because diet and other environmental factors play such a large role.

When we take drugs, such as antibiotics, we can wipe out our microbial diversity, at least in the short term. This is why many have gastrointestinal upset while taking antibiotics. Antibiotics don’t differentiate between good and bad bacteria when they go to work.

One way to counteract these negative effects is to take a probiotic during and after your course of antibiotics. I recommend Renew Life’s 30-50 billion units once a day, two hours after an antibiotic dose and continuing once a day for 14 days after you have finished your prescription. If you really want to ratchet up the protection, you can take one dose of probiotics two hours after each antibiotic dose.

How does the microbiome affect weight?

Many obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

For a long time, the paradigm for weight loss had been to cut calories. However, extreme low-calorie diets were not having a long-term impact. It turns out that our guts may play important roles in obesity and weight loss, determining whether we gain or lose weight.

The results from a study involving human twins and mice are fascinating (2). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. Interestingly, they only lost weight when on a good diet. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not yet clear which bacteria may be contributing these effects.

Does gut bacteria contribute to the development of rheumatoid arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant joint soreness and joint breakdown. What if gut bacteria influenced RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (3). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Although we can’t yet say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, can affect the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. The research is continuing, but we’ve learned a lot already.

References:

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) Science. 2013;341:1241214. (3) PLoS One. 2012;7:e36095. (4) Nutrients. 2019 Dec;11(12):2862.

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

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There are alternatives to sealing yourself indoors

By David Dunaief, M.D.

Dr. David Dunaief

It is officially Spring! Locally, trees are budding, and flowers are beginning to bloom in full force.

If you suffer from seasonal allergies – also known as allergic rhinitis or hay fever – going for a walk is probably a little less enjoyable.

Roughly 25 percent of U.S. adults and 18.9 percent of children were diagnosed with seasonal allergies in 2021, according to the Centers for Disease Control and Prevention (1).

There are quite a few triggers for seasonal allergies. They include pollen from leafy trees and shrubs, grass and flowering plants, as well as weeds, with the majority from ragweed (mostly in the fall) and fungus (summer and fall) (2).

What causes allergic reactions? Seasonal allergy sufferers experience a chain reaction when they inhale allergens (pollen, in this case). The pollen interacts with immunoglobulin E (IgE), antibodies that are part of our immune system and causes mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes, and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response.

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it feels like a common cold, but without the virus. If you have symptoms that last more than 10 days and are recurrent, then it is more likely you have allergies than a virus.

If your allergic rhinitis is not treated properly, you can experience complications like ear infections, sinusitis, irritated throat, insomnia, chronic fatigue, headaches and even asthma (4).

Do medications really help with allergies? The best way to treat allergy attacks is to prevent them, but this means sealing yourself inside. You will need to close the windows, use your air conditioning and, when you do go out, use the recycling vents in your car.

On the medication side, we have intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops.

The guidelines for treating seasonal allergic rhinitis with medications suggest that you use intranasal corticosteroids (steroids) when your quality of life is affected (5). Two well-known inhaled steroids are triamcinolone (Nasacort) and fluticasone propionate (Flonase). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day and can have side effects, like headaches.

If you experience itchiness and sneezing, then second-generation oral antihistamines may be appropriate. These can be taken on an as-needed basis. Second-generation antihistamines, such as loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra), have less sleepiness as a side effect than first-generation antihistamines, like Benadryl, but they don’t work for everyone.

Are there alternative treatments for allergies? Butterbur (Petasites hybridus), an herb, has several small studies that indicate its efficacy in treating hay fever. In one randomized controlled trial (RCT) involving 131 patients, results showed that butterbur was as effective as cetirizine (Zyrtec) (6).

In another RCT, results showed that high doses of butterbur — 1 tablet given three times a day for two weeks — was significantly more effective than placebo (7). Researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) in the trial.

A post-marketing follow-up study of 580 patients showed that, with butterbur Ze339, symptoms improved in 90 percent of patients with allergic rhinitis over a two-week period (8). Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the population.

There are several caveats about the use of butterbur. First, the studies’ durations were short. Second, the leaf extract used in these studies was free of pyrrolizidine alkaloids (PAs). This is very important, since PAs may not be safe. Also, the dose was well-measured, which may not be the case with over-the-counter extracts. Finally, there are interactions with some prescription medications.

Can you treat seasonal allergies with diet? While there are no significant studies on diet, there is one review of literature that suggests that a plant-based diet may reduce symptoms of allergies in teens, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma (9). In my clinical practice, many patients with seasonal allergies have improved and even reversed the course of allergies over time with a vegetable-rich, plant-based diet. This might be due to its anti-inflammatory effects. Analogously, some physicians suggest that their patients have improved after removing dairy from their diets.

While allergies can make you miserable, there are a significant number of over-the-counter and prescription options to help. Diet may play a role by reducing inflammation, although there are no formal studies. There does seem to be promise with some herbs, like butterbur, although there are caveats. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

References: (1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) J Allergy Clin Immunol. 2003 Dec;112(6):1021-31.. (4) J Allergy Clin Immunol. 2010 Jan;125(1):16-29.. (5) Otolaryngol Head Neck Surg. 2015 Feb;2:197-206. (6) BMJ 2002;324:144. (7) Arch Otolaryngol Head Neck Surg. 2004 Dec;130(12):1381-6. (8) Adv Ther. Mar-Apr 2006;23(2):373-84. (9) Eur Respir J. 2001;17(3):436-443. 

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

A lack of exercise may rewire our brains. METRO image

By David Dunaief, M.D.

Dr. David Dunaief

Are 20-somethings more quick-witted than people over 60? You might be surprised by what the research actually tells us. Fear of — and assumptions about —cognitive decline as we age are common. They’re so common that entire industries focus on selling us supplements and games to keep us sharp. Ageism is also a growing concern in society and in the workplace.

What do we really know about the brain? We know that certain drugs, head injuries and lifestyle choices can have negative effects. Numerous neurological, infectious, and rheumatologic disorders and diseases can also have long-term brain effects. These include autoimmune disorders, psychiatric mood disorders, diabetes and heart disease.

Of course, addressing the underlying medical issue is critical. Fortunately, several studies also suggest that we may be able to help our brains function more effectively with rather simple lifestyle changes: sleep, exercise and possibly omega-3s.

What is brain clutter?

Let’s return to our question comparing those in their 20s with those over 60.

German researchers put this stereotype to the test. They found that educated older people tend to have a larger mental database of words and phrases to draw upon when responding to a question (1). When this was factored into their simulation analysis, the difference in terms of age-related cognitive decline became negligible.

The more you know, the harder it becomes to come up with a simple answer to something.

What if we could reboot our brains, just like we do with a computer? This may be possible through sleep, exercise and omega-3s.

How does sleep help with brain functioning?

Researchers have identified a couple of specific values we receive from sleep: one involves clearing the mind, and another involves productivity.

For the former, a study done in mice shows that sleep may help the brain remove waste, such as beta-amyloid plaques (2). When we have excessive plaque buildup in the brain, it may be a sign of Alzheimer’s. When mice were sleeping, the interstitial space (the space between brain structures) increased by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough, because cerebrospinal fluid could reach much farther. A similar effect was seen when the mice were anesthetized.

In an Australian study, results showed that sleep deprivation may have contributed to an almost one percent decline in gross domestic product (3). Why? When people don’t get enough sleep, they are not as productive. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness on short-term basis, we can’t do this continually.

In one small study, sleep deprivation was compared to alcohol impairment (4). It found that subjects’ response time and accuracy with assigned tasks after 17-19 hours without sleep were comparable or worse than their performance when they had a blood-alcohol concentration (BAC) of .05 percent. With more than 19 hours of sleeplessness, performance equaled .1 percent BAC.

Earlier studies showing similar results led my wife to insist on picking me up, rather than letting me drive home, after 24-hour call hospital assignments during my residency. 

Does lack of exercise rewire your brain?

One study with rats suggests that a lack of exercise can cause unwanted new brain connections. Rats that were not allowed to exercise were found to have rewired neurons around their medulla, the part of the brain involved in breathing and other involuntary activities. This included more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (5). 

Among the rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart. We need human studies to confirm this impact.

Do omega-3 fatty acids improve brain volume?

The hippocampus is involved in memory and cognitive function. In the Women’s Health Initiative Memory Study of Magnetic Resonance Imaging Study, results showed that postmenopausal women who were in the highest quartile of measured omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (6). 

Specifically, the researchers looked at the levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes. The source of the omega-3 fatty acids could have been from either fish or supplementation.

It’s never too late to improve brain function. Although we have a lot to learn, we know that there are relatively simple ways we can positively influence it.

References:

(1) Top Cogn Sci. 2014 Jan.;6:5-42. (2) Science. 2013 Oct. 18;342:373-377. (3) Sleep. 2006 Mar.;29:299-305. (4) Occup Environ Med. 2000 Oct;57(10):649-55. (5) J Comp Neurol. 2014 Feb. 15;522:499-513. (6) Neurology. 2014;82:435-442.

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

Injuries from falls can result in a loss of independence. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Taking a tumble can result in broken bones and torn ligaments. These can be serious for older patients, where the consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability and a decline in physical and social activities (1). Ultimately, a fall can lead to loss of independence (2).

What can increase your fall risk?

Of course, there are environmental factors, like slippery or uneven surfaces. Other contributing factors to personal fall risk include age and medication use. Some medications, like antihypertensive medications, which are used to treat high blood pressure, and psychotropic medications, which are used to treat anxiety, depression and insomnia, are of particular concern. Chronic diseases can also contribute.

Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (3).

What are some simple ways to reduce your fall risk?

It is most important to exercise. This means exercises that involve balance, strength, movement, flexibility and endurance, all of which play significant roles in fall prevention (4). The good news is that many of these can be done inside with no equipment or with items found around the home. We will look more closely at the research.

Nonslip shoes are a big help and, during the winter months, footwear that prevents sliding on ice, such as slip-on ice cleats that fit over your shoes.

In the home, inexpensive changes, like securing area rugs, removing tripping hazards, installing grab-bars to your bathroom showers and tubs, and adding motion-activated nightlights can also make a difference.

And, of course, pay attention when you’re walking. Resist the urge to text or read from your mobile device while you’re moving around. A recently published study of young, healthy adults found that texting while walking affected their gait stability and postural balance when they were exposed to a slip hazard (5).

How does medication put you at risk?

There are several medications that heighten fall risk. Psychotropic drugs top the list, but what other drugs might have an impact? A well-designed study showed an increase in fall risk in those who were taking high blood pressure medication (6). Those on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase.

These medications can reduce significantly the risks of cardiovascular disease and events, so physicians need to consider the risk-benefit ratio in older patients before stopping a medication. We also should consider whether lifestyle modifications, which play a significant role in treating this disease, can reverse your need for medication (7).

How much does exercise reduce fall risk?

A meta-analysis showed that exercise significantly reduced the risk of a fall (8). It led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in falls that required medical attention. Even more impressive was a 61 percent reduction in fracture risk.

Remember, the lower the fracture risk, the more likely you are to remain physically independent. The author summarized that exercise not only helps to prevent falls but also fall injuries. Unfortunately, those who have fallen before, even without injury, often develop a fear that leads them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased fall risk (9).

What types of exercise are best?

Any consistent exercise program that improves balance, flexibility, and muscle tone and includes core strengthening can help improve your balance. Among those that have been studied, tai chi, yoga and aquatic exercise have all been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (10). The goal of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the overall number of falls and a 44 percent decline in the number of exercising patients who fell during the six-month trial, with no change in the control group.

If you don’t have a pool available, tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (11).

Another pilot study used modified chair yoga classes with a small assisted-living population (12). Participants were those over 65 who had experienced a recent fall and had a resulting fear of falling. While the intention was to assess exercise safety, researchers found that participants had less reliance on assistive devices and three of the 16 participants were able to eliminate their use of mobility assistance devices.

Our best line of defense against fall risk is prevention with exercise and reducing slipping opportunities. In addition, if you are 65 and older, or if you have arthritis and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before you consider changing your blood pressure medications, review your risk-to-benefit ratio with your physician.

References:

(1) MMWR. 2014; 63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) JAMA. 1995;273(17):1348. (4) Cochrane Database Syst Rev. 2012;9:CD007146. (5) Heliyon. 2023 Aug; 9(8): e18366. (6) JAMA Intern Med. 2014 Apr;174(4):588-595. (7) JAMA Intern Med. 2014;174(4):577-587. (8) BMJ. 2013;347:f6234. (9) Age Ageing. 1997 May;26(3):189-193. (10) Menopause. 2013;20(10):1012-1019. (11) Mater Sociomed. 2018 Mar; 30(1): 38–42. (12) Int J Yoga. 2012 Jul-Dec; 5(2): 146–150.

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

It’s difficult to meet vitamin D needs with sunlight. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

This weekend, we’ll all “Spring forward” to Daylight Saving Time. While we’ll lose an hour of sleep on Sunday, the trade will be more hours of sunshine each day.

If you are like many in the Northeast, this is good news for your vitamin D3 levels. In practice, though, it’s still difficult to get enough sun exposure without putting yourself at higher risk for skin cancer.

There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of a treatment regimen. However, many questions remain.

Many of us receive food-sourced vitamin D from fortified packaged foods, where vitamin D3 has been added. This is because sun exposure does not address all of our vitamin D needs. For example, in a study of Hawaiians, a subset of the study population who had more than 20 hours of sun exposure without sunscreen per week, some participants still had low vitamin D3 values (1).

There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends between 20 and 50 ng/ml, and The Endocrine Society recommends at least 30 ng/ml.

Does body fat affect Vitamin D absorption?

An analysis of data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, found that those with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (2). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs showed none of these benefits.

Does vitamin D increase cardiovascular health?

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. The Framingham Offspring Study showed that patients with deficient levels were at increased risk of cardiovascular disease (3).

However, a small randomized controlled trial (RCT) questioned the cardioprotective effects of vitamin D (4). 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 2,500 IUs. Some of the weaknesses of the study were a very short duration and small study size, so the results were not conclusive.

How does vitamin D affect mortality risk?

In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: nine percent reduction with vitamin D plus calcium and seven 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 amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

Does vitamin D help you lose weight?

There is moderately good news on the weight front. the Study of Osteoporotic Fractures found 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 (6).

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, sufficient vitamin D did not result in weight loss.

USPSTF recommendations and fracture risk

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D3 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (7). The supplement combination does not seem to reduce fractures, but it does increase the risk of kidney stones.

When should you supplement your vitamin D3?

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 might play a role with many disorders. But it is also important not to raise your blood levels too high (8). The range that I tell my patients to target is between 32 and 50 ng/ml, depending on their health circumstances.

References:

(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) JAMA Netw Open. 2023 Published online Jan 2023. (3) Circulation. 2008 Jan 29;117(4):503-511. (4) PLoS One. 2012;7(5):e36617. (5) J Women’s Health (Larchmt). 2012 Jun 25. (6) J Clin Endocrinol Metabol. May 17, 2012 online. (7) JAMA. 2018;319(15):1592-1599. (8) Am J Lifestyle Med. 2021 Jul-Aug; 15(4): 397–401.

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

Even modest exercise can affect your genes. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that we should not rely on exercise for weight loss. Exercise is still important, though. It can alter how our genes express themselves and improve our outcomes with diseases and other health issues, such as diabetes, kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

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

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

Does exercise alter your genes?

While it may not change our genes, exercise may change how our genes express themselves.

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

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

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

Can you treat cardiovascular disease with exercise?

What if we could forgo medications for cardiovascular disease by exercising? One meta-analysis examined 57 studies that involved drugs and exercise. It showed similar benefits in mortality with secondary prevention of coronary heart disease with statins and exercise (7). So, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same study also showed that for those with pre-diabetes, it didn’t matter whether they took metformin or exercised – they had the same effect.

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

Does exercise help with kidney stones?

Anyone who has tried to pass a kidney stone knows it can be excruciating. Most treatments involve taking pain medication and fluids and just waiting for the stone to pass. Truly, the best way to treat kidney stones is to prevent them.

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

Does sexual activity count as exercise?

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

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

Movement and exercise not only help you feel better, they may also influence your genes’ expression. In certain circumstances, they may be as powerful as medications in preventing some diseases.

References:

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

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