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David Dunaief

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Exercises that involve balance, strength, movement, flexibility and endurance all play significant roles in fall prevention. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Taking a tumble can cause broken bones and torn ligaments. While these might not be life-altering in younger folks, they can have serious consequences for older patients, including a decrease in functional ability and a decline in physical and social activities, which can lead to a loss of independence (1)(2). One recent study found that older adults who had suffered a fall had poorer health and well-being two years later when compared to those who had not fallen (3).

What increases your fall risk?

Obviously, environmental factors, like slippery or uneven surfaces, can increase your risk of falling. Age and medication use are also contributing factors. Some medications, like those used to treat high blood pressure or those targeting anxiety, depression and insomnia, are of particular concern. Chronic diseases may also contribute.

If you have upper and lower body strength weakness, decreased vision, a hearing disorder or psychological issues, such as anxiety and depression, these conditions predispose you to falling (4).

How can you reduce your fall risk?

Most importantly, exercise. Exercises that involve balance, strength, movement, flexibility and endurance all play significant roles in fall prevention (5). 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. Look for slippers and shoes with non-skid soles. During the winter, choose footwear that prevents sliding on ice, such as boots with cleats or slip-on ice cleats that fit over your shoes.

In the home, secure area rugs, remove tripping hazards, install grab-bars in your bathroom showers and tubs, and add motion-activated nightlights.

And, of course, always pay attention when you’re walking. Don’t text, read or video chat 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 (6).

How do medications increase risk?

Several medications heighten fall risk, including psychotropic drugs and high blood pressure medications.

A well-designed study showed that those taking moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase (7).

Because these medications can reduce cardiovascular risks, physicians must consider the risk-benefit ratio in older patients before prescribing or stopping a medication. We also should consider whether lifestyle modifications can reverse your need for medication or your dosage (8).

Using exercise to reduce fall risk

A meta-analysis showed that regular exercise significantly reduced the risk of a fall (9). 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. The author summarized that exercise not only helps to prevent falls but also fall injuries.

Unfortunately, those who have fallen before 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 (10).

Any consistent exercise program that focuses on 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 reduce 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 (11). 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.

Tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (12).

Another pilot study used modified chair yoga classes with a small, over-65 assisted-living population where participants had experienced a recent fall and had a resulting fear of falling (13). 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 defense against fall risk is prevention with exercise and managing our environments to reduce fall opportunities. In addition, if you are 65 and older, or if you have arthritis and are over 45, 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) Aging Ment Health. 2021 Apr;25(4):742-748. (4) JAMA. 1995;273(17):1348. (5) Cochrane Database Syst Rev. 2012;9:CD007146. (6) Heliyon. 2023 Aug; 9(8): e18366. (7) JAMA Intern Med. 2014 Apr;174(4):588-595. (8) JAMA Intern Med. 2014;174(4):577-587. (9) BMJ. 2013;347:f6234. (10) Age Ageing. 1997 May;26(3):189-193. (11) Menopause. 2013;20(10):1012-1019. (12) Mater Sociomed. 2018 Mar; 30(1): 38–42. (13) 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.

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 Obesity can influence your body’s ability to use vitamin D

By David Dunaief, M.D.

Dr. David Dunaief

Happy Spring! It’s been a rougher winter than in recent years, and the additional hours of sunshine each day seem even more welcome than usual.

The extra sunshine is also good news for your vitamin D3 levels. Realistically, though, it’s still challenging to get enough sun exposure to meet your vitamin D requirements without putting yourself at risk for developing skin cancer. Even without this concern, sun exposure doesn’t address all our vitamin D needs. In a study of Hawaiians, a subset of the study population with more than 20 hours of sun exposure without sunscreen per week still had some participants with low vitamin D3 values (1).

This is why many of us rely on food-sourced vitamin D from fortified packaged foods, where vitamin D3 has been added. 

Why do we care about vitamin D? Studies have shown that it may be effective in preventing and treating a wide swath of chronic diseases. If you have low levels of vitamin D, replacing it is important. There’s still a lot we don’t know, though.

For example, there is no consensus on the ideal blood level for vitamin D. For adults, the Food and Nutrition Board (FNB) at the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine (IOM)) recommends between 20 and 50 ng/ml (2). The Endocrine Society updated their testing and supplementation recommendations in 2024 to stratify them by age and pregnancy status, among other risk factors (3). Generally, however, they do not recommend testing vitamin D3 levels for healthy adults and defer to the IOM for supplementation recommendations.

How does body fat affect Vitamin D absorption?

Data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, suggests that participants with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (4). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs did not experience these benefits.

According to the National Institutes of Health (NIH), those with obesity issues might need greater intakes of vitamin D to achieve vitamin D levels similar to those of people with lower weights, because subcutaneous fat sequesters vitamin D, making it unavailable for their systems to use (2).

Does vitamin D improve cardiovascular health?

Several observational studies have shown benefits from vitamin D supplementation with cardiovascular disease. The Framingham Offspring Study showed that patients with deficient levels were at increased risk of cardiovascular disease (5).

In contrast, though, a small randomized controlled trial (RCT) questioned the cardioprotective effects of vitamin D (6). 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. 

An NIH review of both observational and randomized clinical trials concluded that, even for those with low vitamin D levels, supplementation does not reduce cardiovascular disease risk (2). 

How does vitamin D affect your 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 were more than 30 ng/ml (7).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this 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.

Does vitamin D supplementation reduce 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 (8). The combination does not seem to reduce fractures, but it does increase the risk of kidney stones.

Should you supplement your vitamin D3?

While vitamin D may not be a cure-all, it might play a role with many disorders. It is important to supplement to optimal levels, especially since many of us living in the Northeast have insufficient to deficient levels. This is especially important for those with specific health issues that are affected by low vitamin D levels. However, it is important not to raise your blood levels too high (9). I advise my patients to target a range between 32 and 50 ng/ml, depending on their health circumstances.

References:

(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) nih.gov. (3) JCEM, August 2024 (online June 2024). (4) JAMA Netw Open. 2023 Published online Jan 2023. (5) Circulation. 2008 Jan 29;117(4):503-511. (6) PLoS One. 2012;7(5):e36617. (7) J Clin Endocrinol Metabol. May 17, 2012 online. (8) JAMA. 2018;319(15):1592-1599. (9) 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.

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It doesn’t take much exercise to improve health outcomes. METRO photo

By David Dunaief, M.D.

As I wrote last week, exercise is not the sole solution for weight loss. However, it can improve our outcomes with diseases and other health issues. It may also play a significant role in altering how our genes express themselves. The list of conditions it can improve includes diabetes, kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Even knowing all the positive impacts, motivating yourself to exercise can be difficult. 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 continue for longer periods (2).

Why is this so important? Because we are too sedentary. According to data from the 2017-2020 Behavioral Risk Factor Surveillance System, New York had among the highest levels of physical inactivity in the U.S., at 25.9 percent of the population (3).

Can 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, when participants exercised for six months, many thousands of genes in fat cells were affected (4). During the study, previously sedentary men took a one-hour spin class twice a week. According to the researchers, this exercise affected genes involved in storing fat and in risk for subsequent diabetes and obesity development. The participants also improved other important health metrics, including cholesterol, blood-pressure, fat percent and, over time, waist circumferences.

Epigenetics is when lifestyle changes ultimately lead to changes in how genes express themselves, turning genes on and off. While this effect has been shown with dietary changes, this is one of the first studies to show that exercise also impacts our genes. It took only six months to see these numerous gene changes with a modest amount of cardiovascular exercise.

Need more inspiration? Another study showed considerable gene changes in muscle cells after one stationary bike workout (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 broadly affects physical and cognitive health (6).

How does exercise affect cardiovascular disease?

One meta-analysis examined 57 studies that involved drugs and exercise. It showed similar mortality benefits with statins and exercise for patients who already have coronary heart disease (7). Both statins and exercise reduced 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 — each had the same effect.

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

Exercise and kidney stone prevention

Passing a kidney stone can be excruciating. Most treatments involve taking pain medication and fluids and just waiting for the stone to pass. Honestly, the best way to treat kidney stones is to prevent them.

The Women’s Health Initiative Observational Study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones. It found exercise reduced kidney stone risk by as much as 31 percent (8). Even better, exercise intensity did not alter 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.

Exercise can have strong influences on the way you feel; however, it may also influence your genes’ expression and, ultimately, affect the development and prevention of disease. In certain circumstances, it may be as powerful as medications and, in combination, can pack a powerful punch.

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.

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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Exercise is an inadequate weight-loss tool

By David Dunaief, M.D.

Dr. David Dunaief

We hear continuously about the importance of exercise. Why is it so important, though? Exercise has benefits for preventing and improving a wide range of medical conditions, from cardiovascular disease, chronic kidney disease, and diabetes to depression, insomnia, fatigue, balance, cognitive decline, and osteoporosis. Will it help you lose weight, though? While gym equipment ads emphasize this, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). It may only reduce fat mass and weight modestly for most people. It might, however, be helpful with weight maintenance.

Ultimately, it may be more important to examine what you are eating than to succumb to the rationalization that you can eat without care and work out to compensate for that extra cookie.

Does exercise help with weight loss?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will promote weight loss. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise, which is characterized as a moderately intense pace.

On the positive side, the women were in better aerobic shape by the study’s end. Also, women who had lost weight at four-weeks were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that exercise alone led to a disappointing amount of weight loss (4). In six months, patients lost a mean of 3.5 pounds, and at 12 months, they lost about 3.75 pounds.

A recent meta-analysis of aerobic exercise studies found that, in order to break through to meaningful reductions in waist circumference and body fat, participants had to exercise more than 150 minutes per week, up to 300 minutes weekly, at moderate to vigorous aerobic intensity (5).

However, exercise may help with weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (6). In another study, when exercise was added to dietary changes, women were able to maintain 30 percent more weight loss than with diet alone after a year (7).

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects about 14 percent of U.S. adults, as one example of exercise’s impact on disease (8).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (9). When walkers were compared to non-walkers, walkers experienced a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death.

The more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times a week saw a 44 percent reduction in death and a 59 percent reduction in kidney replacement. This is significant. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

There are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

References:

(1) Diabetes Spectr. 2017 Aug;30(3):157–160. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) JAMA Netw Open. 2024;7(12):e2452185. (6) Obesity (Silver Spring). 2010;18(1):167. (7) Int J Obes Relat Metab Disord. 1997;21(10):941. (8) cdc.gov. (9) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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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Studies have shown that adding blueberries to your diet can lower your blood pressure. Pixabay photo
Non-clinical readings may paint a more complete picture of your risks

By David Dunaief, M.D.

Dr. David Dunaief

Nearly 120 million U.S. adults, just under half of the population, have hypertension (1). Of these, only 25 percent have successfully controlled their blood pressure to less than 130/80 mmHg, the high end of “normal” blood pressure.

For the remaining 75 percent, the risk of complications, including cardiovascular events and mortality, is significantly higher.

What increases our risk of developing hypertension? An observational study involving 2,763 participants showed that the top three influencers on the risk of developing high blood pressure were poor diet, modest obesity, and cigarette smoking, all of which are modifiable (2).

What increases your risk of complications?

Being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, diabetes, low vitamin D, and too much alcohol all increase your risk (3).

The good news is that you can improve your risk profile (4).

What is the effect of gender?

One of the most concerning complications of hypertension is cardiovascular disease. A large observational study with a 31-year duration found that isolated systolic (top number) hypertension increased the risk of cardiovascular disease and death in both men and women between 18 and 49 years old, compared to those who had optimal blood pressure (5). These complications were not affected by onset age.

When the results were sorted by gender, women experienced the greatest effect, with a 55 percent increased risk of cardiovascular disease and 112 percent increased risk of heart disease death.

When  to measure your blood pressure

Most of us have our blood pressure measured when we’re at a doctor’s office. While measuring blood pressure in a clinic can be useful, a meta-analysis of nine studies showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (5).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. The nighttime readings were achieved using 24-hour ambulatory blood pressure measurements (ABPM).

A factor that might increase the risk of nighttime cardiovascular events is masked uncontrolled hypertension (MUCH).  MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, out-of-clinic readings indicate their blood pressure is uncontrolled.

A study of 167 patients found that medication non-compliance was not a significant factor in those experiencing MUCH (6). Of the participants experiencing MUCH, 85.2 percent were fully adherent with their prescribed medications, a number similar to the group that did not experience MUCH.

Interestingly, in the Spanish Society of Hypertension ABPM Registry, MUCH was most often seen during nocturnal hours (7). The study’s authors suggest that ABPM may be a better way to monitor those with higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

A previous study of patients with chronic kidney disease (CKD) and hypertension suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more of their blood pressure medications at night saw a two-third reduction in cardiovascular event risk.

Blueberries and blood pressure

Diet plays an important role in controlling high blood pressure. Lowering sodium is critically important, but adding berries may also be beneficial.

In a study of post-menopausal women with pre-hypertension or stage one hypertension, daily consumption of 22 grams of blueberry powder, the equivalent of one cup of fresh blueberries, reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over two months (9).

This addition of a modest amount of fruit had a significant impact. Blueberries increase nitric oxide, which helps blood vessels relax and reduces blood pressure. While the study used blueberry powder, an equivalent amount of real fruit might lead to an even greater reduction.

High blood pressure and possible cardiovascular complications can be scary, but lifestyle modifications, such as making dietary changes and taking antihypertensive medications at night, can reduce your risks.

References:

(1) millionhearts.hhs.gov. (2) BMC Fam Pract 2015;16(26). (3) uptodate.com. (4) Diabetes Care 2011;34 Suppl 2:S308-312. (5) J Am Coll Cardiol 2015;65(4):327-335. (6) Hypertension. 2019 Sep;74(3):652-659. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377.

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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Many risk factors can be managed with lifestyle changes

By David Dunaief, M.D.

Dr. David Dunaief

February has been named American Heart Month by the American Heart Association, providing us with a reminder during the Valentine’s Day month to build heart-healthy habits.

Improved medicines, earlier treatment of risk factors, and an embrace of lifestyle modifications have helped reduce the prevalence of heart disease and remind us that it is ultimately preventable.

How do you reduce heart disease risk?

Major heart disease risk factors include obesity, high cholesterol, high blood pressure, smoking and diabetes. Unfortunately, rates of obesity and diabetes are both still rising. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (1).

A key contributor is the standard American diet, which is rich in saturated fat and calories (2). This drives atherosclerosis, fatty streaks in the arteries.

A high resting heart rate is another potential risk factor. 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 beats per minute (bpm) over 80 (3). A normal resting heart rate is typically between 60 and 100 bpm, so a high-normal rate has increased risk.

When does medication help?

Cholesterol and blood pressure medications have reducing some heart disease risk. according to the American Society of Hypertension, compliance with taking blood pressure medications has increased over the last 10 years from 33 to 50 percent.

Statins have also played a role in primary prevention. They lower lipid levels, including total cholesterol and LDL — the “bad” cholesterol. In addition, they lower inflammation levels that contribute to cardiovascular disease risk. The Jupiter trial showed statins contributed to a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients, those with slightly elevated levels of inflammation and normal cholesterol profiles.

Statins do have side effects, though. They’ve been shown to increase the risk of diabetes in intensive dosing, compared to moderate dosing (4). Many who are on statins also suffer from myopathy (muscle pain and cramping).

I’m often approached by patients on statins with this complaint. Their goal is to reduce and ultimately discontinue statins by modifying their diet and exercise plans.

Lifestyle modification is a powerful ally.

Which lifestyle changes reduce heart disease risk the most?

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The Baltimore Longitudinal Study of Aging investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five or more servings of fruits and vegetables daily with <12 percent saturated fat reduced their risk of dying from heart disease by 76 percent, compared to those who did not meet these criteria (5). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet.

The Nurses’ Health Study shows that these results are also seen in women. Lifestyle modification reduced the risk of sudden cardiac death (SCD) (6). This is often 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 factors incorporated, the greater the risk reduction. There was as much as a 92 percent decrease in SCD risk when all four parameters were followed.

In a cohort study of high-risk participants and those with heart disease, patients implemented extensive lifestyle modification: a plant-based, whole foods diet accompanied by exercise and stress management. Study results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life over a very short period — three months from the start of the trial (7). Outside of this study environment, many of my own patients have experienced similar results.

How do you monitor your heart disease risk?

Physicians use cardiac biomarkers, including blood pressure, cholesterol and body mass index, alongside inflammatory markers like C-reactive protein to monitor your risk. Ideally, if you need to use medications to treat risk factors for heart disease, you should strive for short-term intervention. For some, it may be best to use medication and lifestyle changes together; for patients who take an active role, lifestyle modifications may be sufficient.

By focusing on developing heart-healthy habits, you can improve the likelihood that you will be around for a long time.

References:

(1) Diabetes Care. 2010 Feb; 33(2):442-449. (2) Lancet. 2004;364(9438):93. (3) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (4) JAMA. 2011;305(24):2556-2564. (5) J Nutr. March 1, 2005;135(3):556-561. (6) JAMA. 2011 Jul 6;306(1):62-69. (7) 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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Acetaminophen and NSAIDS are not risk-free

By David Dunaief, M.D.

Dr. David Dunaief

What do you do when you have a headache or a sore knee? Most of us head to our medicine cabinet to grab one of the analgesics we keep on hand for such occasions.

Analgesics are, first and foremost, pain relievers, but they also help lower fever and reduce inflammation. The most common over the counter (OTC) medications include acetaminophen and a variety of non-steroidal anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen, and naproxen sodium.

Americans consume more than 30 billion doses of NSAIDs a year, including both OTC and prescription-strength (1). As for acetaminophen, one quarter of Americans take it weekly.  Because they’re so accessible and commonplace, many consider them low risk. Many patients don’t even include them in a list of current medications. I need to specifically ask about them.

They are not risk-free, though. According to a poll of regular OTC NSAID users, 60 percent were not aware that they can have dangerous side effects (2).

What are NSAID risks?

NSAIDs, according to the Centers for Disease Control and Prevention, are responsible for more than 70,000 hospitalizations and 7,600 deaths annually (3). 

They increase the risk of heart attacks, gastrointestinal bleeding, stroke, exacerbation of diverticular disease, chronic arrhythmia (abnormal heartbeat) and erectile dysfunction. In some instances, the cardiovascular effects can be fatal.

The FDA strengthened warning labels on non-aspirin NSAID labels 10 years ago, advising that those taking NSAIDs should immediately seek medical attention if they experienced chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech (4).

Five years ago, the FDA added a warning label to non-aspirin NSAIDs about the risks of fetal kidney damage and pregnancy complications beginning around week 20 of a pregnancy (4).

In a case control study using the UK Primary Care Database, chronic users of NSAIDs between ages 40 and 89 had a significantly increased risk of a serious arrhythmia called atrial fibrillation (5).

Interestingly, researchers defined “chronic users” as patients who took NSAIDs for more than 30 days. These users had a 57 percent increased risk of atrial fibrillation. A Danish study reinforces these results after the first month of use (6). This is not very long to have such a substantial risk. For patients who used NSAIDs longer than one year, the risk increased to 80 percent. 

NSAIDs also increase the risk of mortality in chronic users. Older patients who have heart disease or hypertension (high blood pressure) and are chronic NSAID users are at increased risk of death, according to an observational study (7). Compared to those who never or infrequently used them over about 2.5 years, chronic users had a greater than twofold increase in death due to cardiovascular causes. High blood pressure was not a factor in this study, since chronic users had lower blood pressure; however, I have seen that NSAID use can increase blood pressure with some of my patients.

What are acetaminophen risks?

The FDA announced in 2011 that acetaminophen consumption should not exceed 325 mg every four to six hours when used in a prescription combination pain reliever (4). The goal is to reduce and avoid severe injury to the liver, which can cause liver failure.

There is an intriguing paradox with acetaminophen: Hospitals typically dispense regular-strength 325-mg doses of the drug, whereas OTC doses frequently are found in “extra strength” 500-mg tablets, and often the suggested dose is two tablets, or 1 gram. At the FDA’s request, Tylenol lowered its recommended daily dosage for its extra strength version to no more than 3 grams a day.

One study that showed acute liver failure was due primarily to unintentional overdoses of acetaminophen (8). Accidental overdosing is more likely to occur when taking acetaminophen at the same time as a combination sinus, cough or cold remedy that also contains acetaminophen. OTC and prescription cold medications can contain acetaminophen.

If you already have liver damage or disease, consult your physician before taking any medication.

To protect yourself from potentially adverse events, you must be your own best advocate; read labels, and remember to tell your physician if you are taking any OTC medications.

If you are a chronic user of NSAIDs or acetaminophen because of underlying inflammation, you may find an anti-inflammatory diet and other lifestyle changes can be an effective alternative.

References:

(1) medscape.com. (2) J Rheumatol. 2005;32;2218-2224. (3) Annals of Internal Medicine, 1997;127:429-438. (4) fda.gov. (5) Arch Intern Med. 2010;170(16):1450-1455. (6) BMJ 2011;343:d3450. (7) Am J Med. 2011 Jul;124(7):614-620. (8) Am J Gastroenterol. 2007;102:2459-2463.

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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Design strategies that get you up and moving

By David Dunaief, M.D.

Dr. David Dunaief

Exercise helps build long-term physical and mental health, but regular exercise is often a challenge. Even with all the fitness-related apps to prompt us, modern society has an equal number of tech demotivators. It’s just too easy to let the next episode of our favorite series autoplay or to answer those last few emails.

Even if we want to exercise, we “don’t have time.”

I have good news. There is an easy way to get tremendous benefit in very little time. You don’t need expensive equipment, and you don’t have to join a gym. You can even sharpen your wits with your feet.

Esther Tuttle was profiled in a New York Times’ Science Times article a few years ago, when she was 99. Esther was sharp as a tack and was independently mobile, with no mobility aids. She remained active by walking in the morning for 30 minutes and then walking again in the afternoon. 

Of course, this story is only anecdotal; however, evidence-based medicine supports her claim that walking is a simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away. For the step-counters among you, that’s about 2,000 steps a day for an adult with an average stride length.

Does walking improve mental acuity?

Walking has a dramatic effect, preserving brain function and even growing certain areas of the brain (1). Study participants who walked between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years.

Participants who had an increase in brain tissue volume also experienced a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants with a mean age of 78. All were dementia-free at the trial’s start.

In another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2).

If you’re pressed for time or building your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile?

Does walking affect one’s mood?

Researchers performed a meta-analysis of studies related to the relationship between exercise and depression. They found that adults who walked briskly for about 75 minutes per week cut their risk of depression by 18 percent (3).

If you ratchet up your exercise to running, a study showed that mood also improves, reducing anger (4). The act of running increases your levels of serotonin, a hormone that, when low, can make people agitated or angry.

How do I build better habits?

A common challenge I hear is that working from home reduces much of the opportunity to walk. There’s no walking down the hall to a meeting or to get lunch or even from the car or train to the office. Instead, everything is only a few steps away. Our work environment is working against us.

If you need a little help getting motivated, here is a terrific strategy to get you started: set an alarm for specific points throughout your day and use that as a prompt to get up and walk, even if it’s for only 15 minutes. The miles will add up quickly.

A client of my wife’s schedules meetings for no more than 50 minutes, so she can walk a “lap” around her house’s interior between meetings or even do some jumping jacks. She also looks for opportunities to have an old-fashioned phone call, rather than a video call, so she can walk up and down the hallway while she’s meeting. Of course, this is one person, but it might prompt some ideas that will work for you.

Walking has other benefits as well. Weight-bearing exercise helps prevent osteoporosis and osteoporotic fractures. Sadly, if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles.

Remember to use your feet to keep your mind sharp and yourself even-tempered. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References:

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) JAMA Psychiatry 2022. 79(6), 500-559. (4) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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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Examining heredity vs. dietary impact

By David Dunaief, M.D.

Dr. David Dunaief

Your heart disease risk is influenced by your family’s history. Can you overcome these genetic issues by making lifestyle changes that improve your health trajectory? It’s the classic heredity vs. environment dilemma. Let’s look at the evidence.

A study involving the Paleo-type diet and other ancient diets suggests that cardiovascular disease is influenced by genetics, while another study considering the Mediterranean-type diet suggests that we might be able to reduce our risk factors with lifestyle adjustments. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). 

How do our genes affect our heart disease risk?

Researchers used computed tomography scans to look at 137 mummies from Egypt, Peru, the Aleutian Islands, Southwestern America, and others (2). The represented cultures included hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. All the diets included significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis, or plaques in their arteries, which is a precursor to heart disease. This is a familiar ratio; it’s what we still see in modern times.

The authors concluded that atherosclerosis could be part of the human aging process. In other words, it may be embedded in our genes. We all have genetic propensity toward atherosclerosis and heart disease, some more than others.

However, other studies demonstrate that we can reduce our heart disease risk with lifestyle changes, such as with a plant-rich diet, like the Mediterranean-type diet.

How does diet affect our genetic response?

A study of 7,000+ participants in Spain who were at high risk for cardiovascular disease examined the impacts of a Mediterranean-type diet and a low-fat diet on cardiovascular disease risk (3). Two variations on the Mediterranean-type diet were compared to a low-fat diet, with participants randomly assigned to three different groups. The two Mediterranean-type diet groups indicated about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Risk indicators they studied included heart attacks, strokes and mortality. Interestingly, risk improvement in the Mediterranean-type diets occurred without significant weight loss.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet.

The Mediterranean-type diet arms both included significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. Both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups were wine drinkers, they were encouraged to drink at least one glass a day.

This study was well-designed; however, there was a significant flaw that should temper our enthusiasm. The group assigned to the low-fat diet was not able to maintain this diet throughout the study. As a result, it really became a comparison between variations on the Mediterranean diet and a standard diet.

How have leading cardiovascular and integrative medicine physicians responded to the study? Interestingly, there are two opposing opinions, split by field. You may be surprised by which group liked it and which did not.

Well-known cardiologists hailed the study as a great achievement. They emphasized that we now have a large, randomized diet trial measuring meaningful clinical outcomes. 

On the other hand, leading integrative medicine physicians, including Caldwell Esselstyn, M.D. and Dean Ornish, M.D., expressed disappointment with the results. Both promote plant-rich diets that may be significantly more nutrient-dense than the Mediterranean diet in the study. Both have published their own small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish showed a reversal of atherosclerosis in one of his studies (6).

Their objections to the study revolve around their belief that heart disease and its risk factors can be reversed, not just reduced. In other words, the study didn’t go far enough.

Both opinions have merit. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even with an abundance of included fats, will appeal to a wide audience. However, those who follow a more focused diet that includes more nutrient-dense foods, could potentially see a more significant reversal of heart disease.

Either way, it is encouraging to know that we can alter our cardiovascular destinies by altering our diet.

References:

(1)www.uptodate.com(2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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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Lifestyle modifications including diet can help

By David Dunaief, M.D.

Dr. David Dunaief

In my practice, many patients have resisted telling me they suffered from erectile dysfunction (ED). However, it’s a common problem. Because it can indicate other medical issues, it’s important that you share this information with your doctor.

ED affects about 24 percent of men, on average. If it occurs less than 20 percent of the time, it is considered normal; however, if it occurs more than 50 percent of the time, you should seek help (1). 

Of course, there are oral medications for ED. You’ve probably seen the ads for approved medications, including sildenafil (Viagra, or the “little blue pill”), tadalafil (Cialis), vardenafil (Levitra, Staxyn), and avanafil (Stendra). They work by causing vasodilation, or enlargement of blood vessels, which increases blood flow to the penis. Unfortunately, this does not solve the medical problem, but it does provide a short-term solution for those who are good treatment candidates.

ED’s prevalence generally increases with age. An analysis of the 2021 National Survey of Sexual Wellbeing found that ED affected 12.7 percent of 35-44-year-olds, increased to 25.3 percent of 45-54- year-olds, 33.9 percent of those aged 55-64, 48 percent of those aged 65-74, and 52.2 percent of those aged 75 and older (2).

So, what contributes to the increase as we age? Disease processes and drug therapies.

What is the connection between medical conditions and ED?

Chronic diseases can contribute significantly to ED. ED might also be an indicator of disease. Typical contributors include metabolic syndrome, diabetes, high blood pressure, cardiovascular disease and obesity. In the Look AHEAD trial, ED had a greater than two-fold association with hypertension and a three-fold association with metabolic syndrome (3). In another study, ED was associated with a 2.5-times increase in cardiovascular disease (4).

Patients with ED had significantly more calcification, or atherosclerosis, in their arteries when compared to a control group in a randomized clinical trial (RCT) (5). They were also more than three times as likely to have severe calcification. In addition, they had more inflammation, measured by C-reactive protein. 

Which medications contribute to ED?

About 25 percent of ED cases are thought to be associated with medications, such antidepressants, NSAIDs (e.g., ibuprofen and naproxen sodium), and hypertension medications. Unfortunately, the most common antidepressant medications, SSRIs, have significant impacts on ED. 

The California Men’s Health Study, with over 80,000 participants, showed that there was an association between NSAIDs and ED, with a 38 percent increase in ED in patients who use NSAIDs on a regular basis (6). The authors warn that patients should not stop taking NSAIDs without consulting their physicians.

Also, high blood pressure drugs have a reputation for causing ED. A meta-analysis of 42 studies showed that beta blockers have a small effect, but thiazide diuretics (water pills) more than doubled ED, compared to placebo (7).

How can diet affect ED?

The Mediterranean-type diet has been shown to treat and prevent ED. It’s a green leafy alternative to the little blue pill. Foods are rich in omega-3 fatty acids and high in monounsaturated fats and polyunsaturated fats, as well as fiber. Components include whole grains, fruits, vegetables, legumes, walnuts, and olive oil. 

In two RCTs lasting two years, those who followed a Mediterranean-type diet experienced improvements in their endothelial functioning (8, 9). They also experienced both lower inflammation and lower insulin resistance.

In another study, those who had the highest compliance with a Mediterranean-type diet were significantly less likely to have ED, compared to those with the lowest compliance (10). Even more impressive was that the group with the highest compliance had a 37 percent reduction in severe ED versus the low-compliance group.

A study of participants in the Health Professionals Follow-up Study looked closely at both the Mediterranean-type diet and the Alternative Healthy Eating Index 2010 diet, which emphasized consuming vegetables, fruits, nuts, legumes, and fish or other sources of long-chain fats, as well as avoiding red and processed meats (11). At this point, it probably won’t surprise you to hear that the greater participants’ compliance with either of these diets, the less likely they were to experience ED.

References:

(1) clevelandclinic.org. (2) J Sex Med. 2024;21(4): 296–303. (3) J Sex Med. 2009;6(5):1414-22. (4) Int J Androl. 2010;33(6):853-60. (5) J Am Coll Cardiol. 2005;46(8):1503. (6) Medicine (Baltimore). 2018 Jul;97(28):e11367. (7) JAMA. 2002;288(3):351. (8) Int J Impot Res. 2006;18(4):405-10. (9) JAMA. 2004;292(12):1440-6. (10) J Sex Med. 2010 May;7(5):1911-7. (11) JAMA Netw Open. 2020 Nov 2;3(11):e2021701.

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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