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Taking Vitamin D may reduce the risk of developing Parkinson’s disease. Stock photo
Cumulative lifestyle changes can improve results

By David Dunaief

Dr. David Dunaief

According to the Parkinson’s Foundation, roughly 60,000 Americans are diagnosed with Parkinson’s disease (PD) each year, and approximately one million Americans are living with PD (1). PD is a neurodegenerative (the breakdown of brain neurons) disease with the resultant effect of a movement disorder.

Most notably, patients with the disease suffer from a collection of symptoms known by the mnemonic TRAP: tremors while resting, rigidity, akinesia/bradykinesia (inability/difficulty to move or slow movements) and postural instability or balance issues. It can also result in a masked face, one that has become expressionless, and potentially dementia, depending on the subtype. There are several different subtypes; the diffuse/malignant phenotype has the highest propensity toward cognitive decline (2).

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (3). Why not add back dopamine? Actually, this is the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

There’s a lot we still don’t know about the causes of PD; however, risk factors may include head trauma, reduced vitamin D, milk intake, well water, being overweight, high levels of dietary iron and migraine with aura in middle age.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also with lifestyle modifications. Lifestyle factors include iron, vitamin D and CoQ10. The research, unfortunately, is not conclusive, though it is intriguing.

Reducing iron in the brain

This heavy metal is potentially harmful for neurodegenerative diseases such as Alzheimer’s disease, macular degeneration, multiple sclerosis and, yes, Parkinson’s disease. The problem is that this heavy metal can cause oxidative damage.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (4). This drug was mostly well-tolerated.

The chelator reduced the risk of disease progression significantly on the Unified Parkinson Disease Rating Scale (UPDRS) during the 12-month study. Participants who were treated sooner had lower levels of iron compared to a group that used the chelator six months later. A specialized MRI was used to measure levels of iron in the brain.

The iron chelator does not affect, nor should it affect, systemic levels of iron, only those in the brain specifically focused on the substantia nigra region. The chelator may work by preventing degradation of the dopamine-containing neurons. It also may be recommended to consume foods that contain less iron.

Does CoQ10 slow progression?

When we typically think of using CoQ10, a coenzyme found in over-the-counter supplements, it is to compensate for depletion from statin drugs or due to heart failure. Doses range from 100 to 300 mg. However, there is evidence that CoQ10 may be beneficial in Parkinson’s at much higher doses. In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to the placebo group (5). Other doses of 300 and 600 mg showed trends toward benefit but were not significant. This was a 16-month trial in a small population of 80 patients. Though the results for other CoQ10 studies have been mixed, these results are encouraging. Plus, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with PD.

Is Vitamin D part of the puzzle?

In a prospective (forward-looking) study, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (6). This is quite impressive, especially since the highest quartile patients had vitamin D levels that were what we would qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less. There were over 3,000 patients involved in this study with an age range of 50 to 79.

While many times we are deficient in vitamin D and have a disease, replacing the vitamin does nothing to help the disease. Here, it does. Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In an RCT, results showed that 1,200 IU of vitamin D taken daily, may have reduced the progression of Parkinson’s disease significantly on the UPDRS compared to a placebo over a 12-month duration (7). Also, this amount of vitamin D increased the blood levels by two times from 22.5 to 41.7 ng/ml. There were 121 patients involved in this study with a mean age of 72.

So, what have we learned? Though medication with dopamine agonists is the gold standard for the treatment of Parkinson’s disease, lifestyle modifications can have a significant impact on both prevention and treatment of this disease. Each lifestyle change in isolation may have modest effects, but cumulatively their impact could be significant. The most exciting part is that lifestyle modifications have the potential to slow the progression the disease and thus have a protective effect.

References:

(1) parkinsons.org. (2) JAMA Neurol. 2015;72:863-873. (3) uptodate.com. (4) Antioxid Redox Signal. 2014;10;21(2):195-210. (5) Arch Neurol. 2002;59(10):1541-1550. (6) Arch Neurol. 2010;67(7):808-811. (7) Am J Clin Nutr. 2013;97(5):1004-1013.

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

By David Dunaief, M.D.

Dr. David Dunaief

COVID-19, a strain of the coronavirus, is now a pandemic. I have been barraged with questions from patients, neighbors and friends. They are right to be asking questions, because there is not enough information being circulated about how to protect yourself and your family. 

Key elements

The key weapons we have in this fight against COVID-19 are containment and mitigation. A lot has been shared about containment by the Centers for Disease Control. Containment is reducing the incidence of new cases to a goal of zero, thus flattening the prevalence curve so this virus is no longer infecting anyone. This requires social distancing, hand washing for at least 20 seconds, surface cleaning, and avoiding touching your eyes, nose and mouth (1). If you have not already, I encourage you to review the guidelines at www.cdc.gov/coronavirus.

There is less information being provided about how we can minimize the severity of the disease if we are infected. This is mitigation. Mitigation is about preparing ourselves, so we experience an asymptomatic or a mild form. 

Who is most at risk?

According to a study focusing on Wuhan, China findings, people most at risk are those who have chronic diseases, with high blood pressure, diabetes and heart disease being the three most common (2). Also at risk are those who are “older,” that is 60 years or older, for they are more likely to have weakened immune systems and increased inflammation.

Managing your immune response

Ultimately, the goal is to have a healthy, appropriate immune system response. If the immune system “under-responds,” the virus’s symptoms will be more severe. Another term for this is immunocompromised. 

If the immune system is overstimulated, your white blood cells are more likely to attack healthy tissue and cause further damage, exacerbating the situation. This sometimes happens after a heart attack, where the immune response is overzealous, targets healthy tissue and causes dysfunction in the heart. This process is called remodeling.

The goal is to create a healthy/strengthened immune system — not to boost and not to suppress the immune system. You want the “Goldilocks” of immune responses: not too little, not too much, but just right.

What can be done?

The best methodology here is to lean on what I call the four pillars of lifestyle modification: diet, exercise, stress management, and sleep.  

Diet. By implementing a nutrient-dense, whole food plant-based (WFPB) diet or, more specifically, what I call a “Low Inflammatory Foods Everyday (LIFE) diet,” you can rapidly improve or even reverse these chronic diseases, decrease inflammation and strengthen your immune system, which will decrease your chances of dying from the virus.

The Lancet study referenced above found that inflammation and a weakened immune system were central to determining how people will do on entering the hospital.

What I’ve found with the LIFE diet in my practice is that people have white blood cells that are on the low end of the scale, between 2.5-4.5, rather than in the middle or upper range of 6.0-10.8. Typically, my patients’ white blood cells when they get sick stay within the normal range of 3.4-10.8. In fact., I had a patient who recently got a cold virus: their white blood cells were 3.4 before they got sick, and they rose to only 7.8, well within the normal range. This resulted in a targeted response with recovery in a very short time period. 

For those with healthy immune systems, if they do get the coronavirus, their response will be more likely targeted instead of a disproportionately large response that starts killing the virus but also the healthy tissue in the lungs, leading to increased inflammation and fluid build-up in the lungs. Dr Fauci has warned this could potentially happen – what is called a cytokine storm – although the chances are very small. Ultimately, the immune system in these situations contributes to the problem, instead of helping.

So, what can you do to incorporate LIFE diet habits into your daily routine?

Focus on fresh and frozen fruits, vegetables and legumes. This is very important. With vegetables, the focus should be on dark green leafy vegetables, such as spinach, bok choy, kale, broccoli and cauliflower, as well as mushrooms. More is better. You cannot have too much. For fruits, apples have shown to play an important role in lung health, and all types of berries have high anti-inflammatory effects. 

WFPB diets ultimately help with inflammation and immune strengthening and also support reduced stress and better sleep. The reason for these effects may have to do with the microbiome, the microbes living in your gut, which are an important determinant of how your immune system functions. Seventy percent of your immune cells are in your gut.

You can test for inflammation by looking at both white blood cell count and high sensitivity CRP (hsCRP). Beta carotene levels in the blood are a way to measure nutrient levels. I recently published a study that showed there is an inverse relationship between beta carotene in the blood and inflammation measured through hsCRP. This showed a 75 percent reduction in inflammation with higher beta carotene levels achieved through a plant-rich diet focusing on dark green leafy vegetables.

Interestingly, you don’t seem to achieve the same reduction in inflammation from vitamins or plant-based powders as you do by eating actual fruits and vegetables and legumes.

Stress management and exercise. Please, don’t panic. When you stress, your body releases cortisol, or internal steroids, that actually weaken the immune system and increase your risk of serious infection. Techniques to reduce your stress include exercise, yoga and meditation.

Mild to moderate exercise can be effective, such as a walk or jog outdoors or up and down the steps of your home. Just because the gyms may be closed in your area does not mean you can’t get exercise. It is spring, let’s take advantage of the weather, which will also help with mood and stress.

You can also exercise your lungs using an incentive spirometer. My personal favorite is the Triflo II version, but there are many on the market. I recommend taking 10 breaths using the incentive spirometer twice a day. This can help expand your lungs and keep the aveoli healthy and open. Aveoli exchange oxygen and carbon dioxide molecules to and from the bloodstream.

Sleep. Exercise will also help with sleep, as will the LIFE diet. Getting enough quality sleep is important to strengthening the immune system. Quality, not quantity, is most crucial. 

What if you are infected?

If you are infected, supportive care is most critical: stay hydrated; focus on foods with fluids in them to help with this, like fruits, vegetables, and low-salt vegetable-based soups; and sleep.

Importantly, stay away from NSAIDS. These are mostly over-the-counter medications such as ibuprofen, naproxen and even aspirin, but can be prescriptions such as diclofenac. These suppress the immune system, thus making it more difficult for it to fight (3)(4). The mechanism of action for this suppression of the immune system is an anti-inflammatory effect that is different and detrimental, compared to the favorable anti-inflammatory effects of a WFPB diet such as the LIFE diet.

Instead, you want to reduce fever using acetaminophen, or Tylenol. This will not have any effects on inflammation, thus not interfering with the body’s immune system. If you can’t tolerate acetaminophen for fever, some alternatives may be elderflowers, catnip (which is a gentle choice for children), yarrow, white willow bark, echinacea, and lemon balm, although there is little data on their effectiveness.

Do not hesitate to go to the hospital if you have difficulty breathing, persistent pain or pressure in your chest, new confusion or an inability to get up, or bluish lips or face. These are signs of potentially severe and life-threatening COVID-19 symptoms.

To sum it all up, chronic diseases and not managing those four lifestyle pillars are risk factors for dying from COVID-19. You can improve or reverse your chronic diseases, as well as strengthen your immune system and reduce inflammation through a plant-rich dark green leafy vegetable diet like the LIFE diet

References:

(1) cdc.gov/coronavirus. (2) Lancet. Published online March 9, 2020. (3) Lung. 2017;195(2):201-8. (4) Chest. 2011;139(2):387-94

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.       

 

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Diet may also affect quality of life as we age

By David Dunaief, M.D.

Dr. David Dunaief

Here’s a stunning statistic: 60 percent of American adults have a chronic disease, with 40 percent of adults having more than one (1). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade at around 78.8 years old (2).

Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients, according to the Centers for Disease Control and Prevention (CDC). 

The truth is that many Americans are malnourished. How could that be, when so many are overweight or obese? We are not a developing country, where access to healthy food is more challenging. Still, malnourishment is common at all levels of socioeconomic class. The definition of malnourished is insufficient nutrition, which in the U.S. results from low levels of much-needed nutrients.

I regularly test patients’ carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. They are measurable and give the practitioner a sense of whether the patient may lack potentially disease-fighting nutrients. Testing is often covered if the patient is diagnosed with moderate malnutrition. Because the standard American diet is very low in nutrients, classifying a patient with moderate malnutrition can be appropriate. A high nutrient intake approach can rectify the situation and increase, among others, carotenoid levels.

High nutrient intake

A high nutrient intake is an approach that focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals -— plant nutrients. Micronutrients are bioactive compounds found mostly in foods and some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum is greater than the parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (3).

A 20 percent increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large prospective (forward-looking) cohort study, where the Mediterranean-type diet decreased mortality significantly – the better the compliance, the greater the effect (4). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

Quality of life

Quality of life is also important, though. Let’s examine some studies that examine the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (5). The authors attribute this effect at least partially to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. There are 120 calories per tablespoon of olive oil, all of them fat. If you eat too much, even of good fat, it defeats the purpose. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s. 

In a case-control (compare those with and without disease) study, high intake of antioxidants from food is associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), even when participants had a genetic predisposition for the disease (6). AMD is the leading cause of blindness in those 55 years or older. There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can alter this predicament. Hopefully, with a focus on a high nutrient intake, we can re-ignite the pace of increased life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. (2) macrotrends.net. (3) N Engl J Med 2017; 377:143-153. (4) BMJ. 2009;338:b2337. (5) Neurology June 15, 2011. (6) Arch Ophthalmol. 2011;129(6):758-766.

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

It is important to stay hydrated if you have a history of stone formation. Stock photo
High sodium and hypertension can increase probability

By David Dunaief, M.D.

Kidney stones, or nephrolithiasis, can be asymptomatic (no symptoms at all) or may present with the classic symptoms of blood in the urine and colicky pain. Pain can be intermittent or constant, ranging from dull to extremely painful, described by some as being worse than giving birth, shot or burned. The pain may radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1). 

Lifetime risk of kidney stones is about 19 percent in men and 9 percent in women (2). Once you form one stone, your risk of another within five to seven years is approximately 50 percent.

Stones are usually diagnosed through clinical examination and abdominal x-rays and/or non-contrast CT scans.

Unfortunately, the first line treatment for passing kidney stones – at least small ones – involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are <4mm pass spontaneously. Location is an important factor as well, with stones closest to the opening of the urethra more likely to pass (3).

The good news is there are lifestyle changes that can reduce the risk of kidney stones. First, it is very important to stay hydrated, drinking plenty of fluids, especially if you have a history of stone formation (4).

Calcium supplementation’s impact

One of the easiest methods is to significantly reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones, with calcium oxalate being the dominant one, occurring approximately 80 percent of the time (5). Calcium supplements increase the risk of kidney stones. When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (6). 

According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (7). It did not matter whether participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, the same study found that calcium from dietary sources has the opposite effect, decreasing risk. Those participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest group. Calcium intake should not be too low, for that also increases kidney stone risk. However, the source of calcium is a key to preventing kidney stones. 

Sodium’s effect

It’s important to reduce sodium for many reasons, but this provides one more. Again, in the Nurses’ Health Study, participants who consumed 4.5 g sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 g per day (7). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Animal protein

Animal protein also seems to play a role. In a five-year, randomized clinical trial, men who consumed small amounts of animal protein, approximately two ounces per day, and lower sodium were 51 percent less likely to experience a kidney stone than those who consumed low amounts of calcium (8). These were men who had a history of stone formation. The reason that animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that its higher sulfur content produces more acid, which is neutralized by release of calcium from the bone (9).

Hypertension

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study (a certain population during a specific period) with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (10). Amazingly, it did not matter if the patients were treated for their high blood pressure; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not the symptoms.

The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more changes that you implement, the lower your risk of stones.

References:

(1) emedicine January 1, 2008. (2) kidney.org. (3) J Urol. 2006;175(2):575. (4) J Urol. 1996;155(3):839. (5) N Engl J Med. 2004;350(7):684. (6) Kidney Int 2003;63:1817–23. (7) Ann Intern Med. 1997;126(7):497-504. (8) N Engl J Med. 2002 Jan 10;346(2):77-84. (9) J Clin Endocrinol Metab. 1988;66(1):140. (10) BMJ. 1990;300(6734):1234. 

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

 

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Increasing fiber can reduce hemorrhoid inflammation

By David Dunaief

Dr. David Dunaief

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and child birth. For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms – and often say we “have hemorrhoids” – when we really mean our hemorrhoids are causing us pain. 

When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually bleed, especially during a bowel movement, which may scare us. Fortunately, hemorrhoids are not a harbinger of more serious disease.

There are two types of hemorrhoids: external, occurring outside the anus, and internal, occurring within the rectum. 

How do you treat external hemorrhoids? 

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Thus, they can be self-treated and do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet and supplementation (1). However, sometimes there is thrombosis (clotting) of external hemorrhoids, in which case they may become more painful, requiring medical treatment.

How do you treat internal hemorrhoids?

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they are usually above the point of sensation in the colon, called the dentate line. If the hemorrhoids prolapse below this, there may be pain and discomfort, as well. Prolapse is when hemorrhoids fall out of place, due to weakening of the muscles and ligaments in the colon. 

The first step for treating internal hemorrhoids is to add fiber through diet and supplementation. Study after study shows significant benefit. For instance, in a meta-analysis by the Cochrane Systems Data Review 2005, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, the daily incidence of bleeding was reduced dramatically (3).

There are several minimally invasive options, including anal banding, sclerotherapy and coagulation. The most effective of these is anal banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where two rubber bands are place at the neck of each hemorrhoid. To avoid complications from constipation, patients should also take fiber supplementation. 

Side effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgery) would be the next option.

How do you prevent hemorrhoids?

Adding more fiber to your diet will help prevent hemorrhoids.
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First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing the risk of inflammation. Though you may want private time to read, the bathroom is not the library. As soon as you have finished moving your bowels, it is important to get off the toilet.

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining. Thus, you should try to increase the amount of fiber in your diet, before adding supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes have significant amounts of fiber. Grains, beans and nuts have among the highest levels of fiber. For instance, one cup of black beans has 12 g of fiber. 

Americans, on average, consume 16 g per day of fiber (5). The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 to 38 g, depending on gender and age (6). I typically recommend at least 40 g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65 g per day. You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned – side effects are potentially gas and bloating for the first week or two.

Get plenty of fluids. It helps to soften the stool and prevent constipation. Exercise also helps to prevent constipation. It is important not to hold in a bowel movement; go when the urge is there or else the stool can become hard, causing straining, constipation and more time on the toilet. 

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should see your physician to make sure it is not due to a malignancy or other cause, such as inflammatory bowel disease. The message throughout this article is that Americans need to get more fiber, which is beneficial for inflamed hemorrhoid prevention and treatment.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-456. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-1507. (4) Dis Colon Rectum 2004 Aug;47(8):1364-1370. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1):80–85.

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

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Lowering your meat intake may reduce cataract risk

By David Dunaief, M.D.

Dr. David Dunaief

Cataracts affect a substantial portion of the U.S. population. In fact, 24.4 million people in the U.S. over the age of 40 are currently afflicted, and this number is expected to increase approximately 61 percent by the year 2030 — only 10 years from now — according to estimates by the National Eye Institute (1).

Cataracts are defined as an opacity or cloudiness of the lens in the eye, which decreases vision over time as it progresses. It’s very common for both eyes to be affected. We often think of cataracts as a symptom of age, but we can take an active role in preventing them.

There are enumerable modifiable risk factors including diet; smoking; sunlight exposure; chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity. I am going to discuss the dietary factor.

Prevention

In a prospective (forward-looking) study, diet was shown to have substantial effect on the risk reduction for cataracts (2). This study was the United Kingdom group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

There was an inverse relationship between the amount of meat consumed and cataract risk. In other words, those who ate a great amount of meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork. These results followed what is termed a dose-response curve. 

Compared to high meat eaters, every other group demonstrated a significant risk reduction as you progressed along a spectrum that included low meat eaters (15 percent reduction), fish eaters (21 percent reduction), vegetarians (30 percent reduction) and finally vegans (40 percent reduction). 

There really was not that much difference between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. Thus, you don’t have to become a vegan to see an effect.

In my clinical experience, I’ve also had several patients experience reversal of their cataracts after they transitioned to a nutrient-dense, plant-based diet. I didn’t think this was possible, but anecdotally, this is a very positive outcome and was confirmed by their ophthalmologists.

Mechanism of action

Oxidative stress is one of the major contributors to the development of cataracts. In a review article that looked at 70 different trials for the development of cataract and/or maculopathies, such as age-related macular degeneration, the authors concluded antioxidants, which are micronutrients found in foods, play an integral part in prevention (3).

The authors go on to say that a diet rich in fruits and vegetables, as well as lifestyle modification with cessation of smoking and treatment of obesity at an early age, help to reduce the risk of cataracts. Thus, you are never too young or too old to take steps to prevent cataracts.

How do you treat cataracts?

The only effective way to treat cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens. This is done as an outpatient procedure and usually takes approximately 30 minutes. Fortunately, there is a very high success rate for this surgery. So why is it important to avoid cataracts if surgery can remedy them?

Potential consequences of surgery

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage age-related macular degeneration (AMD) after cataract surgery (4). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients. 

It has been hypothesized that the surgery may induce inflammatory changes and the development of leaky blood vessels in the retina of the eye. However, because this meta-analysis was based on observational studies, it is not clear whether undiagnosed AMD may have existed prior to the cataract surgery, since they have similar underlying causes related to oxidative stress.

Therefore, if you can reduce the risk of cataracts through diet and other lifestyle modifications, plus avoid the potential consequences of cataract surgery, all while reducing the risk of chronic diseases, why not choose the win-win scenario?

References:

(1) nei.nih.gov. (2) Am J Clin Nutr. 2011 May; 93(5): 1128-1135. (3) Exp Eye Res. 2007; 84: 229-245. (4) Ophthalmology. 2003; 110(10): 1960.

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

Kidneys are one of our main stystems for removing toxins and waste. Stock photo
High sodium’s impact extends beyond hypertension

By David Dunaief, M.D.

By now, most of us have been hit over the head with the fact that too much salt in our diets is unhealthy. Still, we respond with “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.” Unfortunately, these are myths. All of us should be concerned about salt or, more specifically, our sodium intake.

Excessive sodium in the diet does increase the risk of high blood pressure (hypertension); the consequences are stroke or heart disease. Approximately 90 percent of Americans consume too much sodium (1).

Now comes the interesting part. Sodium has a nefarious effect on the kidneys. In the Nurses’ Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it may be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

If the salt shaker is not the problem, what is?

 Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of not being able to get her rings off.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this goal. Excess sodium causes the body to retain fluids.

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. 

Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Is sea salt better than table salt? 

High amounts of salt are harmful, and the type is not as important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly salty, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org.

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

Lifestyle modifications, including getting more exercise, can lower blood pressure. Stock photo
Left untreated, high blood pressure has long-term health consequences

By David Dunaief, M.D.

We have focused a large amount of effort on the treatment and prevention of hypertension (high blood pressure) in the U.S. This insidious disorder includes prehypertension —defined as a systolic blood pressure (the top number) of 120-139 mmHg and/or a diastolic blood pressure (the bottom number) of 80-89 mmHg. Prehypertension is pervasive in the United States, affecting approximately one-third of people (1).

The consequences of prehypertension are significant, even though there are often no symptoms. For example, it increases the risk of cardiovascular disease and heart attack dramatically: in an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (2). This is why it’s crucial to treat it in these early stages, even before it reaches the level of hypertension.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (3).

Furthermore, according to the Framingham Heart Study, the risk of sustained hypertension increases substantially the higher the baseline blood pressure (4).

This may or may not impact mortality, but it certainly does impact morbidity (sickness). Quality of life may be dramatically reduced with heart disease, heart attack and hypertension.

Treatment of prehypertension

In my view, it would be foolish not to treat prehypertension. Recommendations for treatment, according to the Joint National Commission (JNC) 7, the association responsible for guidelines on the treatment of prehypertension and hypertension, are lifestyle modifications (5). These involve a Mediterranean-type diet called DASH (Dietary Approaches to Stop Hypertension), with a focus on fruits, vegetables, reduction in sodium to a maximum of 1,500 mg (⅔ of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis). 

Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (6). Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

The danger in treating prehypertension comes only when medication is used, due to side effects. 

Unfortunately, the Trial of Preventing Hypertension (TROPHY) suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (7). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Yet the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, the makers of the drug. 

In an editorial, Dr. Jay I. Meltze, a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (8). 

Prehypertension is an asymptomatic disorder that has been shown to respond well to lifestyle changes — why create symptoms with medication? Therefore, I don’t recommend treating prehypertension patients with medication. Thankfully, the JNC7 agrees.

However, it should be treated -— and treated with lifestyle modifications. The side effects from this approach are only better overall health. Please get your blood pressure checked at least on an annual basis.

References:

(1) cdc.gov. (2) Stroke 2005; 36: 1859–1863. (3) Hypertension 2006;47:410-414. (4) Lancet 2001;358:1682-6. (5) nhlbi.nih.gov. (6) Archives of Internal Medicine 2001;161:589-593. (7) N Engl J Med. 2006;354:1685-1697. (8) Am J Hypertens. 2006;19:1098-1100.

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

All fruits, vegetables, whole grains, nuts, seeds and beans contain some fiber. Stock photo
Fiber has powerful effects on disease prevention and reversal

By David Dunaief, M.D.

Many people worry about getting enough protein, when they really should be concerned about getting enough fiber. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases in the way that studies illustrate with fiber. 

Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily. 

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber rich.

Fiber has very powerful effects on our overall health. A very large prospective cohort study showed that fiber may increase longevity by decreasing mortality from cardiovascular disease, respiratory diseases and other infectious diseases (1). Over a nine-year period, those who ate the most fiber, in the highest quintile group, were 22 percent less likely to die than those in the lowest group. Patients who consumed the most fiber also saw a significant decrease in mortality from cardiovascular disease, respiratory diseases and infectious diseases. The authors of the study believe that it may be the anti-inflammatory and antioxidant effects of whole grains that are responsible for the positive results. 

Along the same lines of the respiratory findings, we see benefit with prevention of chronic obstructive pulmonary disease (COPD) with fiber in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities study (2). The specific source of fiber was important. Fruit had the most significant effect on preventing COPD, with a 28 percent reduction in risk. Cereal fiber also had a substantial effect but not as great.

Does the type of fiber make a difference? One of the complexities is that there are a number of different classifications of fiber, from soluble to viscous to fermentable. Within each of the types, there are subtypes of fiber. Not all fiber sources are equal. Some are more effective in preventing or treating certain diseases. Take, for instance, a February 2004 irritable bowel syndrome (IBS) study (3). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Fiber also has powerful effects on breast cancer treatment. In a study published in the American Journal of Clinical Nutrition, soluble fiber had a significant impact on breast cancer risk reduction in estrogen negative women (4). Most beneficial studies for breast cancer have shown results in estrogen receptor positive women. This is one of the few studies that has illustrated significant results in estrogen receptor negative women. 

The list of chronic diseases and disorders that fiber prevents and/or treats also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease dependent. However, if you are trying to prevent chronic diseases in general, I would recommend getting fiber from a wide array of sources. 

Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased energy levels. Certainly, while protein is important, each time you sit down at a meal, rather than asking how much protein is in it, you now know to ask how much fiber is in it. 

References:

(1) Arch Intern Med. 2011;171(12):1061-1068. (2) Amer J Epidemiology 2008;167(5):570-578. (3) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (4) Amer J Clinical Nutrition 2009;90(3):664–671. 

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

Stocking the fridge with healthy foods is a great way to start off the New Year. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

It is now the second week in January, and most of us have made a New Year’s resolution – or many of them. You’ve taken the first step, but how do you increase the “stickiness factor,” a term used by Malcolm Gladwell in his book, “The Tipping Point”?

Setting a goal that is simple and singular helps. We often overdo it by focusing on multiple resolutions, like eating better, exercising more and sleeping better. While these are all admirable, their complexity diminishes your chances of success. Instead, pick one to focus on, and make the desired impact part of your goal. For example, improve health by losing weight and reversing disease. 

Changing habits is always hard. There are some things that you can do to make it easier, though. 

Your environment is very important. According to Dr. David Katz, director, Yale-Griffin Prevention Research Center, it is not as much about willpower as it is about your environment. Willpower, Katz notes, is analogous to holding your breath underwater; it is only effective for a short timeframe. Thus, he suggests laying the groundwork by altering your environment to make it conducive to attaining your goals. Recognizing your obstacles and making plans to avoid or overcome them reduces stress and strain on your willpower. 

According to a study, people with the most self-control utilize the least amount of willpower, because they take a proactive role in minimizing temptation (1). Start by changing the environment in your kitchen.

Support is another critical element. It can come from within, but it is best when reinforced by family members, friends and co-workers. In my practice, I find that patients who are most successful with lifestyle changes are those where household members are encouraging or, even better, when they participate in at least some portion of the intervention, such as eating the same meals.

Automaticity: Forming new habits

When does a change become a new habit? The rule of thumb used to be it takes approximately three weeks. However, the results of a study at the University of London showed that the time to form a habit, such as exercising, ranged from 18 to 254 days (2). The good news is that, though there was a wide variance, the average time to reach this automaticity was 66 days, or about two months.

Lifestyle modification: Choosing a diet

U.S. News & World Report released its annual ranking of diets last week (3). Three of the diets highlighted include the DASH (Dietary Approach to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. These were the top three for heart health. The Mediterranean diet was ranked number one overall, and the DASH diet was ranked second. Both the Ornish and the DASH diets ranked in the top six. 

What do all of the top diets have in common? They focus on nutrient-dense foods. In fact, the lifestyle modifications I recommend are based on a combination of the top diets and the evidence-based medicine that supports them.

For instance, in a randomized crossover trial, which means patients, after a prescribed time, can switch to the more effective group, showed that the DASH diet is not just for patients with high blood pressure. The DASH diet was more efficacious than the control diet in terms of diabetes (decreased hemoglobin A1C 1.7 percent and 0.2 percent, respectively), weight loss (5 kg/11 lb vs. 2 kg/4.4 lb), as well as in HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (4). 

Interestingly, patients still lost weight, although caloric intake and the percentages of fats, protein and carbohydrates were the same between the DASH and control diets. However, the DASH diet used different sources of macronutrients. The DASH diet also contained food with higher amounts of fiber, calcium and potassium and lower sodium. 

Therefore, diets high in nutrient-dense foods may be an effective way to lose weight while treating and preventing disease. 

I will share one more tip: Take it day by day, rather than obsessing on the larger picture. Health and weight loss can – and should – go together.

References:

(1) J Pers Soc Psychol. 2012;102:22-31. (2) European Journal of Social Psychology, 40: 998–1009. (3) www.usnews.com. (4) Diabetes Care. 2011;34:55-57.

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