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David Dunaief

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The DASH diet is a flexible eating plan that helps create a heart-healthy eating style for life. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. Unlike a heart attack, it develops slowly over years and may take a long time to become symptomatic. According to the latest statistics, 6.7 million Americans over the age of 19 are affected (1).  These numbers are projected to increase to 8.7 million by 2030, with the greatest growth among those aged 35 to 64 (2).

There are two types of heart failure, systolic and diastolic. Put simply, the difference is that the output of blood with each contraction of the heart’s left ventricle is generally preserved in diastolic HF, while it can be significantly reduced in systolic HF.

Fortunately, both types can be diagnosed with an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath during daily activities or when lying down; edema or swelling in the feet, legs, ankles or stomach, reduced exercise tolerance; and feeling tired or weak. These can have a significant impact on your quality of life.

Major lifestyle risk factors for heart failure include obesity, smoking, poor diet, being sedentary, excessive alcohol intake (3). Medical conditions that increase your risk include diabetes, coronary artery disease, high blood pressure, and valvular heart disease.

Heart failure can be treated with medication, including blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. All of these have side effects. We are going to look at recent studies that examine the role of diet in reducing your risk. 

The role of antioxidants in your diet

If we look beyond the risk factors mentioned above, some studies have explored the role oxidative stress may play an important role in contributing to HF.

In an analysis of the Swedish Mammography Cohort, researchers showed that a diet rich in antioxidants reduces the risk of developing HF (4). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. The antioxidants were mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for most of the effect.

This study was the first to investigate the impact of dietary antioxidants on heart failure prevention.

This was a large study: it involved 33,713 women with 11.3 years of follow-up. Still, there are limitations, because it was an observational study, and the population involved only women. However, the results are very exciting, and there is little downside to applying this approach.

Applying the DASH diet

A 2022 study examined the effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the risk of developing HF (5). This study included over 76,000 men and women, ages 45-83 and without previous HF, ischemic heart disease or cancer from the Cohort of Swedish Men and the Swedish Mammography Cohort.

The DASH diet emphasizes consuming fruit, vegetables, whole grains, nuts and legumes, and low-fat dairy and de-emphasizes red and processed meat, sugar-sweetened beverages, and sodium.

The researchers found that long-term adherence to the DASH diet was associated with a lower risk of HF. The greater the participants’ adherence, the greater the positive effect.

Interestingly, even replacing one serving per day of red and processed meat with one serving per day of other DASH diet foods was associated with an approximate 10 percent lower risk of HF.

Comparing a variety of diets

The REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (6). 

Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF. Compared with the lowest quartile, the highest quartile of adherence to the plant-based dietary pattern was associated with a 41 percent lower risk of HF. 

The highest adherence to the Southern dietary pattern was associated with a 72 percent higher risk of HF after adjusting for age, sex, and race and for other potential confounding factors. Researchers found less effect after further adjusting for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease.

They did not observe any associations with the other 3 dietary patterns.

These studies suggest that we should seek to prevent heart failure with dietary changes, including consuming higher amounts of antioxidant-rich foods, such as fruits and vegetables, and lower amounts of red and processed meats.

References:

(1) Circulation. 2024;149:e347–913. (2) hfsa.org. (3) cdc.gov. (4) Am J Med. 2013 Jun:126(6):494-500. (5) Eur J of Prev Cardiology 2022 May: 29(7): 1114–1123. (6) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045.

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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Lowering inflammation and expanding lung capacity are keys

By David Dunaief, M.D.

Welcome to autumn! It’s the time of year when we revel in the beauty of changing foliage, the joy of Halloween decorations and costumes, and the prevalence “pumpkin spice” everything.

Unfortunately, it’s also the time of year when we are most alert to influenza (the flu), respiratory syncytial virus (RSV), and COVID-19 variants circulating in our communities.

If you have a lung disease, such as chronic obstructive pulmonary disease (COPD) or asthma, or if you smoke or vape, the consequences of these viruses are especially concerning.

The good news is that you can do a lot to improve your lung function by exercising, eating a plant-based diet with a focus on fruits and vegetables, expanding your lung capacity with an incentive spirometer, and quitting smoking or vaping (1). 

Does diet improve lung function?

It’s no surprise that your dietary choices can help or hinder your health. What is surprising is diet’s impact on your lung health. Let’s review some of the studies.

In a randomized controlled trial (RCT), results show that asthma patients who ate a high-antioxidant diet had greater lung function after 14 days than those who ate a low-antioxidant diet (2). They also had lower inflammation at 14 weeks, which was measured using a c-reactive protein (CRP) biomarker. Participants in the low-antioxidant group were over two times more likely to have an asthma exacerbation.

The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Using carotenoid supplementation in place of antioxidant foods did not affect inflammation. The authors concluded that an increase in carotenoids from diet has a clinically significant impact on asthma in a very short period.

In a longer-term analysis of the Coronary Artery Risk Development in Young Adults (CARDIA) Study, researchers assessed and stratified diets into three tiers to identify the impacts of diet quality on long-term lung health (3). Researchers found that a nutritionally-rich plant-centered diet was associated with significantly less decline in lung function over 20 years, even after adjusting for demographic and lifestyle factors influencing lung health.

What is the impact of fiber on COPD risk?

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers.

In one study of men, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (4). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain. The “high-fiber” group was still below the American Dietetic Association’s recommended intake of 14 grams per 1,000 calories each day.

In another study, this time with women, participants who consumed at least 2.5 serving of fruit per day, compared to those who consumed less than 0.8 servings per day, experienced a highly significant 37 percent decreased risk of COPD (5).

Both studies used apples, bananas, and pears to reduce COPD risk.

What exercise helps improve lung function?

In a study involving healthy women aged 65 years and older, results showed that 20 minutes of high-intensity exercise three times a day improved FEV1 and FVC, both indicators of lung function, in just 12 weeks (7). Participants began with a 15-minute warm-up, then 20 minutes of high-intensity exercise on a treadmill, followed by 15 minutes of stretching.

You do not need special equipment. You can walk up steps or hills in your neighborhood, do jumping jacks, or even dance around your home. It’s most important to increase your heart rate and expand your lungs. If this is new for you, consult a physician and start slowly. Your stamina will improve quickly when you do it consistently.

What is incentive spirometry?

An incentive spirometer (IS) is a device that helps expand the lungs when you inhale through a tube and cause one or more balls to rise. This inhalation expands the lung’s alveoli.

Incentive spirometry has been used for patients with pneumonia, those who have had chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (8). A small study showed that those who trained with an incentive spirometer for two weeks increased their lung function and respiratory motion. Participants were 10 non-smoking healthy adults who took five sets of five deep breaths twice a day, totaling 50 deep breaths per day. 

In recent years, some small studies examined the impact of IS on patient COVID-19 outcomes. One study of 48 patients in an outpatient setting found that study participants using an IS three times a day experienced a 16 percent increase in maximal inspiratory volume over a span of 30 days (9).

Another pilot study followed 10 patients diagnosed with moderate COVID-19 to determine whether IS use prevented development of Acute Respiratory Distress Syndrome (ARDS) (10). IS users had improved PaO2/FiO2 ratio, improved chest X-ray findings, shorter hospital stays, and sooner improvement of symptoms than non-users.

We all should be working to strengthen our lungs. Using a three-pronged approach including diet, aerobic exercise, and incentive spirometer can make a tremendous difference.

References:

(1) Public Health Rep. 2011 Mar-Apr; 126(2): 158-159. (2) Am J Clin Nutr. 2012 Sep;96(3):534-43. (3) Res Sq  [Preprint]. 2023 Apr 26:rs.3.rs-2845326. [Version 1] (4) Epidemiology Mar 2018;29(2):254-260. (5) Int J Epidemiol Dec 1 2018;47(6);1897-1909. (6) J Phys Ther Sci. Aug 2017;29(8):1454-1457. (8) Ann Rehabil Med. Jun 2015;39(3):360-365. (9) Cureus. 2021 Oct 4;13(10):e18483. (10) Eur Resp J 2022 60: 268.

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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Addressing sleep apnea can avert serious health consequences

By David Dunaief, M.D.

Dr. David Dunaief

Quality sleep feels like it can be elusive these days. Yet, our physical and mental wellbeing depends on getting restful sleep. For those with obstructive sleep apnea (OSA), it can be particularly challenging.

Sleep apnea is defined as an abnormal breathing pause that occurs at least five times an hour while sleeping. While there are many potential causes, the most common is airway obstruction. Some estimates suggest that about 39 million people suffer from sleep apnea in the United States (1).

OSA diagnoses are classified in tiers from mild to severe. The American Academy of Sleep Medicine (AASM) estimates that roughly 80 percent of moderate and severe OSA sufferers are undiagnosed.

Most risk factors for OSA are modifiable. They include excess weight or obesity, alcohol use, smoking, hypertension, type 2 diabetes, and hyperlipidemia (high cholesterol) (2). 

How do you know what to look for?

OSA symptoms include daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration, and morning headaches. While these are significant quality of life issues, OSA is also associated with an array of more serious health consequences, such as cardiovascular disease, high blood pressure and depression.

Fortunately, there is an array of treatment options, including continuous positive airway pressure (CPAP) devices, oral appliances, positional sleep therapy, and lifestyle modifications.

Sleep apnea and cardiovascular disease risk

In a study of 1,116 women over a six-year duration, cardiovascular mortality risk increased in a linear fashion with the severity of OSA (3). For those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death; for those in the severe group, this risk jumped to 250 percent. However, the good news is that treating patients with CPAP decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients.

Another study of 1,500 men with a 10-year follow-up showed similar risks of cardiovascular disease with sleep apnea and benefits from CPAP treatment (4). The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in curbing these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA by 38 and 125 percent, respectively (5). But, as in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

OSA and cancer risk

There have been conflicting study results about the associations between OSA and cancer risk. To reconcile these, a 2023 study of over 62,000 patients in Sweden were followed. Researchers found that OSA was associated with cancer prevalence, independent of other confounding factors (6). 

In a previous study of sleep apnea patients under age 65, researchers also showed an increased risk of cancer (7). The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk. The authors believe that intermittent low levels of oxygen, caused by the many frequent short bouts of breathing cessation, may be responsible for the development of tumors and their subsequent growth.

OSA and male sexual function

Erectile dysfunction (ED) may also be associated with OSA and, like other outcomes, CPAP may decrease this incidence. This was demonstrated in a small study involving 92 men with ED (8). The surprising aspects of this study were that, at baseline, the participants were overweight, not obese, on average and were only 45 years old. In those with mild OSA, CPAP had a beneficial effect in more than 50 percent of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

Other studies have varying results, depending on the age and existing health challenges of study participants. Researchers have suggested that other underlying health problems may be the cause in some patient populations.

Can diet help with OSA?

For some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or it may be used in combination with CPAP to improve results.

In a small study of those with moderate-to-severe OSA, a low-energy diet showed positive results. A low-energy diet implies a low-calorie approach, such as a diet that is plant-based and nutrient-rich. In the study, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (9). The results endured for at least one year.

If you think you are suffering from sleep apnea, you should be evaluated at a sleep lab and follow up with your physician.

References:

(1) ncoa.org. (2) Diseases. 2021 Dec; 9(4): 88. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) BMJ Open. 2023; 13(3): e064501. (7) Am J Respir Crit Care Med. 2012 Nov. 15. (8) Sleep. 2012;35:A0574. (9) BMJ. 2011;342:d3017.

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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Emphasis put on screening, diet and exercise

By David Dunaief, M.D.

Dr. David Dunaief

Currently, approximately 30 percent of new cancer diagnoses in women are breast cancer (1). While age is a risk factor for breast cancer, 16 percent of 2024 diagnoses will be in women under age 50.

This October, for Breast Cancer Awareness month, let’s review the latest research on screening, treatments, and prevention strategies.

What are current screening recommendations?

In April 2024, the U.S. Preventive Services Task Force expanded their screening recommendations for women of average breast cancer risk. They lowered the recommended start point for mammograms to age 40, continuing every other year through age 74 (2).

The American College of Obstetricians and Gynecologists is reviewing their recommendations in light of this USPSTF shift. They currently encourage a process of shared decision-making between patient and physician to determine age and frequency of exams, including whether to begin exams before age 50 or to continue after age 75 (3). Generally, it recommends beginning annual or biennial mammograms starting no later than 50 and continuing until age 75. 

The American Cancer Society’s physician guidelines are to offer a mammogram beginning at age 40 and recommend annual exams from 45 to 54. At age 55 until life expectancy is less than 10 years, they recommend biennial exams (4).

You should consult with your physician to identify your risk profile and plan your regular screening schedule.

Does diet matter?

A small, eight-week randomized control trial of 32 women who had metastatic breast cancer and who were on stable treatment found that the 21 study subjects who ate a whole food, plant-based diet free from added oils and fats lost more weight and reported feeling healthier than the 11 who maintained their current, traditional American diet as part of the control group (5). In addition to losing weight and reporting better emotional well-being and quality of life, they reported less diarrhea and fatigue and experiencing less shortness of breath during activities.

Medical measures of improved health, in addition to weight loss, included reduced insulin resistance and better cholesterol measures. While cancer progression markers did not move significantly in eight weeks, they did show improvement.

The study authors recommend larger and longer follow-up studies to assess the longer-term impact of diet.

What’s the role of exercise?

We know exercise is important in diseases and breast cancer is no exception. An observational trial found that exercise reduced breast cancer risk in postmenopausal women significantly (6). These women exercised moderately; they walked four hours a week over a four-year period. If they exercised previously, five to nine years ago, but not recently, no benefit was seen. The researchers stressed that it is never too late to begin exercise.

Only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. 

A recently published French study assessed cancer recurrence of over 10,000 women with an average age of 56 who were diagnosed with early-stage breast cancer between 2012 and 2018 (7). The researchers found that pre-menopausal women who completed 90 minutes to five hours of moderate exercise per week before starting treatment for hormone receptor-negative breast cancer had a lower risk of metastatic recurrence than women who didn’t exercise.

We need to expend as much energy and resources emphasizing exercise for prevention as we do screenings.

What about soy?

Soy may actually be beneficial in reducing breast cancer risk. In a meta-analysis, those who consumed more soy saw a significant reduction in breast cancer compared to those who consumed less (8). There was a dose-response curve among three groups: high intake of >20 mg per day, moderate intake of 10 mg and low intake of <5 mg.

Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk when compared to those who consumed the least. In addition, higher soy intake has been associated with reduced recurrence and increased survival for those previously diagnosed with breast cancer (9). The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

A more recent meta-analysis of six observational studies expanded on these outcomes (10). It concluded that post-menopausal women and women diagnosed with estrogen receptor-positive breast cancer lowered their breast cancer recurrence risk the most by eating 60 mg of soy isoflavones per day, or two-to-three servings. A serving consists of either one cup of soy milk, three ounces of tofu, or one-half cup of cooked soybeans.

Breast Cancer Awareness Month is a good time to reflect on the importance of mammography and breast self-exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a plant-based diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence or recurrence.

References:

(1)breastcancer.org (2) uspreventiveservicestaskforce.org. (3) acog.org. (4) cancer.org. (5) Breast Cancer Res Treat. 2024 Jun;205(2):257-266. (6) Cancer Epidemiol Biomarkers Prev. 2014 Sep;23(9):1893-902. (7) J Clinical Oncology. 2024;42(25). (8) Br J Cancer. 2008; 98:9-14. (9) JAMA. 2009 Dec 9; 302(22): 2437–2443. (10) JNCI Cancer Spectrum, Volume 8, Issue 1, February 2024, pkad104.

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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Dietary changes can reduce inflammatory factors

By David Dunaief, M.D.

Dr. David Dunaief

The common thread for more than 80 different autoimmune diseases is that the body’s immune system is attacking organs, tissues and cells and causing chronic inflammation (1). Type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, multiple sclerosis, Crohn’s disease, and inflammatory bowel disease are among the list of frequently occurring ones. Unfortunately, autoimmune diseases tend to cluster (2). This means that once you have one, you are at high risk for developing others.

Immunosuppressive therapies

Immunosuppressive therapies are the most prevalent treatment for autoimmune issues. As the name suggests, these reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors.

There are several concerning factors with these treatments.

First, they have substantial side effect profiles. They increase the risks for cancers, opportunistic infections and even death (3). Opportunistic infections can include diseases like tuberculosis and invasive fungal infections.

It makes sense that suppressing the immune system would increase the likelihood of infections. It’s also not surprising that cancer rates would increase, since the immune system helps fend off malignancies. One study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term clinical trials; however, many patients are prescribed these therapies for 20 or more years.

What other possibilities are there to treat autoimmune diseases? Studies are underway that test the efficacy of medical nutrition therapy using bioactive compounds and supplementation. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

Medical nutrition 

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including c-reactive protein (CRP), and improvements in joint pain and other quality of life issues.

What are the effects of fish oil?

Fish oil may help your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). A typical recommendation is to consume about 2 grams of EPA plus DHA to help regulate the immune system. Don’t take these high doses of fish oil without consulting your doctor, because fish oil can have blood-thinning effects.

Do probiotics help?

Approximately 70 percent of your immune system lives in your gut. Probiotics have immune-modulating effects that decrease inflammation by populating the gut with live beneficial microorganisms. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that have been shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Does increasing fiber help?

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one randomized controlled trial, 30 grams, or about one ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

Can diet reduce medication needs?

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Bioactive compounds found in high-nutrient foods and supplements can have a profound impact on your immune system’s regulation and may help reset the immune system. Even in severe cases, bioactive compounds in foods may work in tandem with medications to treat autoimmune diseases more effectively and help reduce dosing of some immunosuppressives, minimizing potential side-effects.

This is not hypothetical. I have seen these effects in my practice, where patients have been able to reduce – or even eliminate – immunosuppressives by altering their diets.

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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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Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Stock photo
Other disorders may contribute to the condition

By David Dunaief, M.D.

Dr. David Dunaief

If you are among the estimated 10 to 15 percent of the population that suffer from irritable bowel syndrome (IBS) symptoms, managing them can be all-consuming (1). IBS symptoms, which can include abdominal pain, cramping, bloating, constipation and/or diarrhea, have a direct effect on your quality of life.

While there is no single test that provides an IBS diagnosis, physicians eliminate other possibilities and use specific criteria to provide a diagnosis.

The Rome IV criteria are an international effort to help diagnose and treat disorders of gut-brain interaction (2). Using these criteria, which include questions about the frequency of pain over the past three months alongside a physical exam, helps provide a diagnosis.

Once diagnosed, first-line treatment typically involves lifestyle modifications, including dietary changes. Let’s look at what the research tells us.

Is IBS affected by mental state?

The “brain-gut” connection refers to the direct connection between mental state, such as nervousness or anxiety, to gastrointestinal issues, and vice versa.

Mindfulness-based stress reduction was used in a small, but randomized, eight-week clinical trial with IBS (3). Those in the mindfulness group (treatment group) showed statistically significant results in decreased severity of symptoms compared to the control group, both immediately after training and three months post-therapy.

Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.

A subsequent meta-analysis of six randomized controlled trials (RCTs) that studied the effects of mindfulness on IBS found that the combined study group achieved improved quality of life and lower pain scores, perceived stress anxiety, and visceral sensitivity than the control group (4).

Interestingly, a 2021 international study of more than 50,000 participants found that there were some genetic similarities among those who suffer from IBS and those who suffer from common mood and anxiety disorders such as anxiety, depression, and neuroticism, as well as insomnia. As the authors wrote, “Although IBS occurs more frequently in those who are prone to anxiety, we don’t believe that one causes the other – our study shows these conditions have shared genetic origins, with the affected genes possibly leading to physical changes in brain or nerve cells that in turn cause symptoms in the brain and symptoms in the gut” (5). In other words, they may have a common cause.

Is gluten a factor?

Gluten sensitivity may be an important factor for some IBS patients (6).

In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo, 68 percent vs. 40 percent, respectively (7). These results were highly statistically significant, and the authors concluded that nonceliac gluten intolerance may exist. 

What role does fructose play?

Some IBS patients may suffer from fructose intolerance. In a study, IBS researchers used a breath test to explore this possibility (8). The results were dose-dependent, meaning the higher the dose of fructose, the greater the effect researchers saw. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients did.

The symptoms of fructose intolerance included gas, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that fructose avoidance may reduce symptoms in some IBS sufferers.

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (9). Foods with high levels of fructose include certain fruits, like apples and pears.

Is lactose intolerance a contributor?

According to another small study, about one-quarter of patients with IBS also have lactose intolerance (10). 

Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptoms at both six weeks and five years when placed on a lactose-restricted diet.

Though the trial was small, the results were statistically significant. Both the patient compliance and long-term effects were excellent, and outpatient clinic visits were reduced by 75 percent.

Will probiotics help?

A study that analyzed 42 trials focused on treatment with probiotics shows there may be a benefit to probiotics, although each trial’s objectives, or endpoints, were different (11).

Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.

All of these studies provide hope for IBS patients — and the research is continuing with assessments of peppermint oil consumption and gut-directed hypnotherapy, among others. Since the causes can vary, a strong patient-doctor relationship can assist in selecting an approach that provides the greatest relief for each patient’s symptoms.

References:

(1) American College of Gastroenterology [GI.org]. (2) J Neurogastroenterol Motil. 2017 Apr; 23(2): 151–163. (3) Am J Gastroenterol. 2011 Sep;106(9):1678-1688. (4) J Clin Med. 2022 Nov; 11(21): 6516. (5) Nat Genet 53, 1543–1552 (2021). (6) Am J Gastroenterol. 2011 Mar;106(3):516-518. (7) Am J Gastroenterol. 2011 Mar;106(3):508-514. (8) Am J Gastroenterol. 2003 June; 98(6):1348-1353. (9) J Clin Gastroenterol. 2008 Mar;42(3):233-238. (10) Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944. (11) Aliment Pharmacol Ther. 2012 Feb;35(4):403-413.

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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Removing iron accumulation may improve results

By David Dunaief, M.D.

Dr. David Dunaief

Patients with Parkinson’s disease (PD) suffer from a variety of movement disorders caused by a breakdown of brain neurons. While we don’t fully understand the causes of PD, we know that risk factors may include head trauma, genetics, exposure to toxins and heavy metals, and other issues, such as a sedentary lifestyle.

The prime culprit is dopamine deficiency that occurs in a region at the base of the brain (1). Because of this, the mainstay of medical treatment has been adding back dopamine; however, eventually the neurons themselves break down, and the medication becomes less effective.

Newer approaches include medications and deep brain stimulatory surgery, as well as modifying lifestyle, considering factors like iron, inflammation, CoQ10, and vitamin D. While the research is not conclusive, it is continuing. This provides us with hope and more options.

Iron accumulation

Iron accumulation is potentially harmful in neurodegenerative diseases such as Parkinson’s disease, as well as Alzheimer’s disease, macular degeneration, and multiple sclerosis, because of the oxidative damage it can cause.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (2).

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 the brain’s iron levels.

A subsequent small RCT of 22 early-onset PD sufferers found a trend for improvement at the same dosing of DFP, results did not achieve statistical significance by the conclusion of the six-month trial (3). 

An iron chelator does not affect systemic levels of iron, only those in the substantia nigra region of the brain. The chelator may work by preventing degradation of the dopamine-containing neurons. Your physician may also recommend that you consume foods that contain less iron.

Inflammation

In a 2023 study, researchers tested 58 newly diagnosed PD participants’ blood and compared their results to 62 healthy control participants to compare inflammatory markers (4). Some PD-arm participants had additional testing done, including cerebrospinal fluid samples and brain imaging.

Researchers found that those with PD had significantly higher brain inflammation levels than those without PD in specific regions. Their blood and cerebrospinal fluid also had high inflammatory markers. These measures correlated with worse visuospatial and cognitive scores.

While this study provides hints of possible treatments, we need additional studies to confirm whether the inflammation is a cause or an effect of PD.

Regardless, adopting a low-inflammatory diet might help mitigate some symptoms of PD or slow its advancement.

CoQ10

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 a 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. In this study, CoQ10 was well-tolerated at even the highest dose.

Unfortunately, a 2022 meta-analysis of CoQ10 studies concluded that it was not universally beneficial, even if some studies showed benefits for specific patients (6). The authors concluded that a personalized approach to its administration and follow-up is critical.

Vitamin D

Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

A prospective study of over 3000 patients showed 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 (7). This is impressive, especially since the highest quartile patients had vitamin D levels that were insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less.

In an RCT with 121 patients, results showed that 1,200 IU of vitamin D taken daily may have reduced the progression of PD significantly on the UPDRS compared to a placebo over a 12-month duration (8). Also, this amount of vitamin D increased the blood levels by almost two times from 22.5 to 41.7 ng/ml. 

In a 2019 study of 182 PD patients and 185 healthy control subjects, researchers found that higher serum vitamin D levels correlated to reduced falls and alleviation of other non-motor PD symptoms (9).

Like other PD research, investigations into the role of Vitamin D are ongoing.

So, what are our takeaways? Though medication is the gold standard for Parkinson’s disease treatment, lifestyle modifications can have a significant impact on both its prevention and treatment. While each change in isolation may have modest effects, their cumulative impact could be significant.

References:

(1) uptodate.com. (2) Antioxid Redox Signal. 2014;10;21(2):195-210. (3) Sci Rep. 2017; 7: 1398. (4) Movement Disorders. 2023;38;5:743-754. (5) Arch Neurol. 2002;59(10):1541-1550. (6) J Pers Med. 2022 Jun; 12(6): 975. (7) Arch Neurol. 2010;67(7):808-811. (8) Am J Clin Nutr. 2013;97(5):1004-1013. (9) Neurologica. 2019;140(4):274-280.

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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Can increasing your nutrient consumption improve your quality of life?

By David Dunaief, M.D.

Dr. David Dunaief

What percent of U.S. adults do you think meet the daily requirements for vegetable intake? How about for fruit intake?

According to a 2022 report by the Centers for Disease Control and Prevention (CDC), an average of 10 percent of U.S. adults meet vegetable intake recommendations, and only 12.3 percent meet the daily requirements for fruit intake (1). That’s abysmal. As you might expect, it follows that we are deficient in many key micronutrients (2).

Why should we care? Fruits and vegetables include fiber, along with critical nutrients and micronutrients that reduce our risks of developing chronic diseases.

Many chronic diseases can be prevented, modified and even reversed by focusing on increasing our nutrients.

Do you want another stunning statistic? More than 50 percent of American adults have one chronic disease, and 27 percent have more than one (3). This is a likely contributor to the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade.

How do you know if you’re getting enough nutrients? One indicator that we can measure is carotenoid levels. Carotenoids are incredibly important for tissue and organ health. I measure my patients’ levels regularly, because they give me a sense of whether the patient might be low in potentially disease-fighting nutrients. A high nutrient intake dietary approach can increase both carotenoid and other critical nutrient levels.

What is a high nutrient intake diet?

A high nutrient intake diet focuses on micronutrients, which literally means “small nutrients.” Micronutrients are bioactive compounds found mostly in foods and in some supplements. They interact with each other in synergistic ways, meaning the sum of them is greater than their parts. Diets that are plant-rich can raise your micronutrient levels considerably.

While fiber is not considered a micronutrient, it also has significant disease modifying effects. A high nutrient intake diet will also increase your fiber intake, adding to the benefits.

A 2017 study included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study. During the 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 (4).

A 20 percent increase in diet scores, which indicated improved diet quality, was significantly associated with reducing total mortality by 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 more than participants with consistently low diet scores. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. As expected, 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 cohort study, where the Mediterranean-type diet decreased mortality significantly — the greater the participants’ compliance, the greater the effect (5).

Can diet improve your quality of life?

Quality of life is as important as longevity. Let’s examine some studies that consider 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 (6). The authors attribute this effect partially to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting consumption to one tablespoon a day. If you eat too much of even good fat, it can be counterproductive. 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 disease.

In a case-control study that compared those with and without disease, high intake of antioxidants from food was 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 (7). AMD is the leading cause of blindness in those over age 54 (7).

Of the 2,167 people enrolled in the study, representing several different genetic variations that made them high risk for AMD, those with the 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 how their genes were expressed. 

Though many Americans are malnourished, increasing our nutrient consumption can improve our outcomes. With a focus on a high nutrient intake diet, we can improve life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. Morb Mortal Wkly Rep 2022;71:1–9. (2) cdc.gov/nutritionreport (3) cdc.gov. (4) N Engl J Med 2017; 377:143-153. (5) BMJ. 2009;338:b2337. (6) Neurology June 15, 2011. (7) Arch Ophthalmol. 2011;129(6):758-766.

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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Drink plenty of water each day to prevent the reoccurence of kidney stones. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

How do you know you have a kidney stone? Most often, you’ll have classic symptoms of blood in the urine and pain. The pain can range from dull to extremely painful, described by some as being worse than giving birth, being shot or being burned, and it might radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1).

Stones are usually diagnosed by a physician through the symptoms, urine tests, and either an abdominal x-ray, a non-contrast CT scan, or an ultrasound.

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 passes. Usually stones that are smaller than four millimeters pass spontaneously. If they’re close to the opening of the urethra, they are more likely to pass on their own (2).

In the case of a stone too large to pass naturally, a urologist may use surgery, ultrasound, or a combination of methods to break it into smaller pieces, so you can pass it naturally.

Unfortunately, once you’ve formed one stone, your likelihood of having more increases significantly over time. The good news is that there are lifestyle changes you can make to reduce your risk.

The number one cause of kidney stones is lifestyle factors, including excessive animal protein or salt intake or too little consumption of items like citrate, fiber, and alkali foods, such as leafy greens and other non-starchy vegetables (3).

Stay hydrated

First, it is crucial that you stay hydrated by drinking plenty of fluids (4). You can help yourself in this process by consuming plenty of fruits and vegetables that are moisture-filled.

Reduce calcium supplements

One of the simplest methods is to reduce your intake of calcium supplements, including foods fortified with calcium. There are several types of stones. Calcium oxalate stones are the most frequent type, occurring approximately 80 percent of the time (5). Calcium supplements, therefore, 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 study participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, calcium from dietary sources has the opposite effect, decreasing risk. In the same study, participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest consumption group. Paradoxically, calcium intake shouldn’t be too low, either, since that also increases risk. Changing your source of calcium is an important key to preventing kidney stones.

Lower your sodium intake

Again, in the Nurses’ Health Study, participants who consumed 4.5 grams of sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 grams per day (7). Why would that be? Increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher risk of stones.

Reduce your animal protein consumption

Animal protein may play a role. In a five-year, randomized clinical trial of men with a history of kidney stones, men who reduced their consumption of animal protein to approximately two ounces per day, as well as lowering their sodium, were 51 percent less likely to experience a kidney stone than those who consumed a low-calcium diet (8).

The reason animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that animal protein’s higher sulfur content produces more acid. The acid is neutralized by release of calcium from the bone (9). That calcium then promotes kidney stones.

Manage your blood pressure

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study 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 whether or not the patients were treated for high blood pressure with medications; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not just the symptoms.

While the causes of kidney stones are complex, making relatively simple lifestyle changes is the most constructive way to avoid the potentially excruciating experience of kidney stones. The more that you implement, the lower your likelihood of stones.

References:

(1) emedicine January 1, 2008. (2) J Urol. 2006;175(2):575. (3) Adv Urol. 2018; 2018: 3068365. (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. 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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Processed meats increase health risks

By David Dunaief, M.D.

Dr. David Dunaief

For many, Labor Day weekend signals the beginning of a regular ritual of making school lunches or, for those of us who work from an office, our own lunches. Sandwiches are typical fare, because they travel well and are easy to handle.

Unfortunately, common sandwich ingredients, including processed meats, are increasingly implicated as potential causes of diseases, including several cancers, heart disease, stroke and diabetes.

Processed meats are those that have been cured, salted, fermented or smoked. Turkey and roast beef were often in my lunch box when I was growing up. The prevailing thought at the time was that deli meats made without artificial nitrates, nitrites and preservatives were healthy. Unfortunately, more recent studies show otherwise.

According to a study in the European Journal of Epidemiology, high processed meat intake was positively associated with risk of breast, colorectal, colon, rectal, and lung cancers (1).

Increased stroke risk

In a large, prospective cohort study, results showed a 23 percent increased risk of stroke in men who consumed the most processed meats (2). Deli meats, including low-fat turkey, ham and bologna, considered healthy by some, were implicated. The 40,291 Swedish participants were followed for about ten years.

The increased risk could be attributed potentially to higher sodium content in processed meats. Another mechanism could be nitrates and nitrites. Interestingly, participants were mostly healthy, except for the processed meats. Thus, processed meats could interfere with the benefits of a heart-healthy diet, according to the authors.

Increased cancer risk

In the large prospective Multiethnic Cohort Study, there was a 68 percent increased risk of pancreatic cancer in participants who consumed the highest amounts of processed meats compared to the lowest (3). Participants were followed for seven years. The authors believe that carcinogenic substances in meat preparation, not necessarily fat or saturated fat, were the reason for increased risk. Pancreatic cancer is deadly, since most patients don’t have symptoms; therefore, it’s not discovered until its very late stages.

Processed meats also increase the risk of colorectal cancer. In a meta-analysis, there was an increased risk of 14 percent per every 100 grams, or 3.5 ounces (approximately one serving) of processed meat per day (4). Two slices of deli meat are equal to one serving. A deli’s turkey sandwich often includes about five servings of processed meat in one meal. 

In the EPIC trial, a prospective study with more than 420,000 participants, processed meats increased the risk of colorectal cancer by 35 percent (5). The absolute risk of developing colorectal cancer was 71 percent over ten years for those who were age 50.

Other cancers implicated in processed meats include lung, liver and esophageal cancers, with increased risks ranging from 20-60 percent according to the NIH AARP Diet and Health study (6). A separate analysis of the EPIC trial showed that there was a greater than two times increased risk of esophageal cancer with processed meats (7).

Type 2 Diabetes risk

In one of the most prestigious and largest meta-analyses involving the Health Professionals’ Follow-up Study and the Nurses’ Health Study I and II, results demonstrated a 32 percent increased risk of type 2 diabetes in participants who had a one-serving increase of processed meat consumption per day (8). This data was highly statistically significant and involved over four million years of cumulative follow-up. Interestingly, the authors estimate that replacing processed meat with one serving of nuts, low-fat dairy and whole grains would reduce risk substantially.

Other lunchbox options

Consider making bowls that include greens, grilled vegetables, healthy grains and beans. These can be prepared in a batch and distributed among lunch-sized containers that can be grabbed from the refrigerator when preparing lunches. If you want to include meat, add small cubes of unprocessed meat you’ve prepared yourself, which can lower your sodium and nitrate consumption.

References:

(1) Eur J Epidemiol. 2021 Sep;36(9):937-951. (2) Am J Clinical Nut. 2011;94 (2):417-421. (3) J Natl Cancer Inst 2005;97 (19): 1458-1465. (4) PLoS One. 2011;6 (6):e20456. (5) J Natl Cancer Inst. 2005 Jun 15;97 (12):906-16. (6) PLoS Med. 2007 Dec;4 (12):e325. (7) J Natl Cancer Inst. 2006 Mar 1;98 (5):345-54. (8) Am J Clinical Nutrition 2011;94 (4): 1088-1096.

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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