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David Dunaief

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Dietary changes can have a dramatic effect

By David Dunaief, M.D.

Dr. David Dunaief

When we say we “have hemorrhoids,” what we really mean is that our hemorrhoids are irritating and painful. Hemorrhoids are vascular structures that help control our stool, and they can become inflamed.

This type of hemorrhoid pain is very common. Both men and women experience it, although women have a higher propensity during pregnancy and childbirth.

When our hemorrhoids are irritated, we may experience itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They can also bleed, especially during a bowel movement, which can be scary. Fortunately, they don’t portend more serious diseases.

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

Treating external hemorrhoids

Fortunately, external hemorrhoids tend to be mild and can be treated with over-the-counter options. These analgesic creams or suppositories contain hydrocortisone. Another treatment option is a sitz bath.

For a more complete solution, the most effective way to reduce hemorrhoid bleeding and pain is to increase your fiber intake (1). 

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should consult your physician to confirm it is not due to a malignancy or other cause, such as inflammatory bowel disease.

Treating internal hemorrhoids

Internal hemorrhoids are a bit more complicated. The primary symptom is bleeding with bowel movement. Because the hemorrhoids are usually above the point of sensation in the colon, called the dentate line, there is rarely pain. If there is pain and discomfort, it’s often because the internal hemorrhoids have prolapsed, or fallen out of place, due to weakening of the muscles and ligaments in the colon. This allows them to fall below the dentate line.

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

What are the treatments for persistent hemorrhoid pain?

There are several minimally invasive options to address persistent and painful hemorrhoids, including banding, sclerotherapy and coagulation. The most effective of these is banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where rubber bands are placed at the neck of each hemorrhoid to cut off the blood flow. 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.

What can help prevent hemorrhoid problems?

Sitting on the toilet for a long time puts a lot of pressure on the veins in the rectum, which can increase your risk of inflammation. As soon as you have finished moving your bowels, it is important to get off the toilet.

Soften the stool and prevent constipation by drinking plenty of fluids. Exercise also helps. You should not hold in a bowel movement; go when you have the urge to keep the stool from becoming hard, which can lead to straining and more time on the toilet.

Consuming more fiber helps create bulk for your bowel movements, reducing constipation, diarrhea and undue straining.

How much fiber should I consume?

Americans, on average, consume about 16g per day of fiber (5). This is well below the U.S.D.A.’s recommendation: 14 grams of fiber for every 1,000 calories we consume (6). The difference between guidelines and actual consumption has prompted the medical community to express concern about the “fiber gap.”

Fiber underconsumption has greater implications than just hemorrhoids. It contributes to weight control issues, increased insulin sensitivity and chronic inflammation, among others (7). Fiber’s benefits are so great that I recommend many patients target 40 grams a day.

You may want to increase your fiber consumption gradually to minimize the potential for gas and bloating during the first week or two. It will take your system a bit of time to adjust.

I typically recommend making diet adjustments before trying supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes all have significant amounts of fiber. Grains, beans and nuts have among the highest levels. For instance, one cup of black beans contains 12g of fiber.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-6. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-7. (4) Dis Colon Rectum 2004 Aug;47(8):1364-70. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85. (7) Nutrients. 2020 Oct; 12(10): 3209.

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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Supplements may not have the same benefits

By David Dunaief, M.D.

Dr. David Dunaief

A cataract is an opacity or cloudiness of the eye’s lens, which decreases vision as it progresses. Although there are different types of cataracts, most often it’s caused by oxidative stress. As we age, the likelihood increases that cataracts will affect our vision.

In the U.S., estimates suggest that 26.6 million Americans over age 40 have a cataract in at least one eye or have had surgery to remove a cataract (1). By age 80, this increases to approximately 50 percent of Americans.

Chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity can contribute to your risk.

The good news is that we can take an active role in preventing cataracts. Protecting your eyes from the sun and injuries, quitting smoking, and increasing your consumption of fruits and vegetables can improve your odds. Here, we will focus on the dietary factor.

What effect does meat consumption have on cataracts?

Diet has been shown to have substantial effect on cataract risk (2). One of the most expansive studies on cataract formation and diet was the Oxford (UK) 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 cataract risk and the amount of meat consumed. In other words, those who ate more meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork.

Compared to high meat eaters, every other group demonstrated a significant reduction in risk as they 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 was not much difference in meat consumption 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. This suggests that you can achieve a meaningful effect by reducing or replacing your average meat intake, rather than eliminating meat from your diet.

I’ve had several patients experience cataract reversal after they transitioned to a nutrient-dense, plant-based diet. This positive outcome and was confirmed by their ophthalmologists.

Do antioxidants help prevent cataracts?

Oxidative stress is one of the major contributors to cataract development. 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 eye disease 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. You are never too young or too old to take steps to protect your vision.

Among antioxidant-rich foods studied that have shown positive effects is citrus. The Blue Mountains Eye Study found that participants who had the highest dietary intake of vitamin C reduced their 10-year risk for nuclear cataracts (4). The same effect was not seen with vitamin C supplements. Instead, a high dose of a single-nutrient vitamin C supplement actually increased cataract incidence (5).

How effective is cataract surgery?

The only effective way to correct cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens in an outpatient procedure. Fortunately, this surgery has a very high success rate.

Of course, there are always potential risks with invasive procedures, such as infection, even when the chances of complications are low. In a small percentage of cases, surgery complications have resulted in blindness.

You can reduce your risk of cataracts with diet and other lifestyle modifications, plus avoid potential consequences from cataract surgery, all while reducing your risk of other 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) Am J Clin Nutr. 2008 Jun; 87(6):1899-1305. (5) Nutrients. 2019 May; 11(5): 1186.

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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Sauces and breads are among the sneakiest offenders

By David Dunaief, M.D.

Dr. David Dunaief

If you have high blood pressure, you’ve probably been told to reduce your sodium. But what about the rest of us? 

According to the Centers for Disease Control and Prevention, about 90 percent of Americans consume too much sodium. This puts our health at risk — and not just for high blood pressure (1).

What are the effects of too much sodium?

In addition to increasing our risk of high blood pressure (hypertension), with consequences like stroke and heart disease, sodium can affect our kidney function, even without high blood pressure.

The Nurses’ Health Study evaluated kidney function in approximately 3,200 women, assessing estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a daily sodium intake of 2,300 mg had a much greater chance of a 30 percent or more reduction in kidney function when compared to those who consumed 1,700 mg per day.

Kidneys are an important part of our systems for removing toxins and waste. They are also where many hypertension medications work, including ACE inhibitors, ARBs, and diuretics (water pills). If kidney function declines, it can 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.

What are sodium recommendations?

Interestingly, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon. If you’ve been paying attention, you’ve probably noticed that’s the same level that led to negative effects in the study. However, Americans’ average intake is 3,400 mg a day (1).

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the FDA and the American Heart Association indicate an upper limit of 2,300 mg per day (3, 4). The American Heart Association goes further, suggestion an “ideal” limit of no more than 1,500 mg per day (3).

What are the biggest sodium sources?

More than 70 percent of our sodium intake comes from processed and packaged foods and from restaurants, not the saltshaker. There is nothing wrong with eating out or ordering in on occasion, but you can’t control how much salt goes into your food. Even when you request “no salt,” many items are pre-seasoned, and sauces can contain excessive amounts of sodium.

One approach to reduce your sodium intake 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. This is not the same as foods labeled “reduced sodium.” These have 25 percent less than the full-sodium version, which doesn’t mean much. For example, soy sauce has about 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon.

Salad dressings, sauces and other condiments, where serving sizes are small, add up quickly. Mustard has about 120 mg per teaspoon. Most of us use more than one teaspoon. Make sure to read the labels on all packaged foods and sauces very carefully, checking for sodium and for serving size. In restaurants, ask for sauces on the side and use them sparingly, if at all.

Bread products are another hidden source. Most contain a decent amount of sodium. I have seen a single slice of whole wheat bread include up to 200 mg. of sodium. That’s one slice. Make a sandwich with four ounces of lower sodium deli meat and mustard, and you could easily consume 1240 mg in a single sandwich.

Soups and canned goods are notoriously high in sodium. There are a few on the market that have no sodium. Look for these and add your own seasonings. Restaurant soups are a definite “no.”

Become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as cheeses, sweet sauces and salad dressings. Put all sauces and dressings on the side, so you can control how much — if any — you choose to use.

Is sea salt better than table salt?

Are sea salts better for you than table salt? Not really. They can have a slightly lower level of sodium, but that’s because their crystal shape means fewer granules fit in a teaspoon. I recommend not using either. In addition to causing health issues, salt dampens your taste buds, masking other flavors.

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 so, and you will notice new flavors in unsalted foods.

When seasoning your food at home, use salt-free seasonings, like Trader Joe’s 21 Seasoning Salute or, if you prefer a salty taste, consider a salt substitute, like Benson’s Table Tasty.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org. (4) fda.gov.

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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A potassium-rich diet may help to reduce blood pressure. Stock photo
Drugs may not be necessary in early stages

By David Dunaief, M.D.

Dr. David Dunaief

High blood pressure affects over 48 percent of U.S. adults (1). This scary number means that almost 50 percent of us are at increased risk for heart attack and stroke, the two most frequent causes of death (2). It also puts us at higher risk for chronic kidney disease and dementia (3).

Hypertension severity is categorized into three stages, or levels of severity, each with a different recommended treatment regimen. When the stages were created in 2017, what we used to call “prehypertension” was split into two new categories: elevated blood pressure and hypertension stage 1.

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg. Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of 80-89 mmHg (4). You can find a simple chart of all levels on The American Heart Association’s website: www.heart.org.

Both have significant consequences, even though there are often no symptoms.

In an analysis of the Framingham Heart Study, researchers found that those with prehypertension experienced a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease (5). Many other studies support these increased risks (6, 7). This is why it’s critical to address increased blood pressure, even in these early stages.

The good news is that new and extended studies have given us clearer insights about effective treatments, stratifying our approaches to improve outcomes.

What’s the best treatment for elevated blood pressure?

The Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, included lifestyle modifications at the top of its recommendations for elevated blood pressure (8).

Lifestyle changes include dietary changes. A Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet are both good options.

Any diet you select should focus on increasing your intake of fruits and vegetables and reducing your daily sodium consumption to no more than 1500 mg (two-thirds of a teaspoon) (9). You should also ensure you exercise, manage your weight, and consume no more than modest amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (8).

Some studies have also shown that a potassium-rich diet helps to reduce blood pressure (9). 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 can precipitate a heart attack.

Some drugmakers have advocated for using medication to treat elevated blood pressure. The Trial of Preventing Hypertension (TROPHY) suggested the use of a hypotensive agent, the blood pressure drug candesartan to treat prehypertensive patients (10)(11). 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. The study was funded by Astra-Zeneca, which made Atacand, a brand version of the drug. 

In an editorial, Jay I. Meltze, M.D., 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 (12). 

Since elevated blood pressure responds well to lifestyle changes, why add medication when there are no long-term benefits? I don’t recommend using medication to treat elevated blood pressure patients, and the JNC8 agrees.

Do lifestyle changes treat Stage 1 hypertension?

For those with Stage 1 hypertension, but with a low 10-year risk of cardiovascular events, these same lifestyle modifications should be implemented for three-to-six months. At this point, a reassessment of risk and blood pressure will determine whether the patient should continue with lifestyle changes or if they need to be treated with medications (13). 

Your physician should assess your risk as part of this equation.

I am encouraged that the role of lifestyle modifications in controlling hypertension has been recognized and is influencing official recommendations. When patients and physicians collaborate on a lifestyle approach that drives improvements, the side effects are only better overall health.

References:

(1) cdc.gov. (2) NCHS Data Brief. 2022;456. (3) Hypertension 2020;75:285-92. (4) heart.org. (5) Stroke 2005; 36: 1859–1863. (6) Hypertension 2006;47:410-414. (7) Am Fam Physician. 2014 Oct 1;90(7):503-504. (8) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (9) Arch of Internal Medicine 2001;161:589-593. (10) N Engl J Med. 2006;354:1685-1697. (11) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (12) Am J Hypertens. 2006;19:1098-1100. (13) Hypertension. 2021 Jun;77(6):e58-e67.

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

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There are 8 grams of fiber in one cup of raspberries. Source: Mayo Clinic, Pixabay photo

Most Americans consume only half   the recommended daily fiber.

By David Dunaief, M.D.

Dr. David Dunaief

Based on an abundance of research, we should all be concerned with getting enough fiber in our diets (1). Most Americans are woefully deficient in fiber, consuming between 10 and 15 grams per day, which is about half of what we should be consuming. Probably not surprising, our consumption of legumes and dark green vegetables is the lowest in comparison to other fiber subgroups (2). This has significant implications for our health.

USDA fiber intake recommendations vary based on gender and age. For adult women, they recommend between 22 and 28 grams per day, and for adult men, the targets are between 28 and 35 grams (2). Some argue that even these recommendations are on the low end of the scale for optimal health.

Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to increase your fiber consumption; you just have to be aware of which foods are fiber-rich.

What difference does fiber type make?

There are a number of different fiber classifications, including soluble, viscous, and fermentable. Within each of the types, there are subtypes. Not all fiber sources are equal.

At a high level, we break dietary fiber into two overarching categories: soluble and insoluble. Soluble fibers slow digestion and nutrient absorption and make us feel fuller for longer. Sources include oats, peas, beans, apples, citrus fruits, flax seed, barley and psyllium.

On the other hand, insoluble fibers accelerate intestinal transit, which promotes digestive health. Sources include wheat bran, nuts, berries, legumes and beans, dark leafy greens, broccoli, cabbage and other vegetables. 

Many plant-based foods contain both soluble and insoluble fiber.

How does fiber affect disease progression and longevity?

Fiber has powerful effects on our 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 (3). Over a nine-year period, those who ate the most fiber were 22 percent less likely to die than those consuming the lowest amount.

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.

A study published in 2019 that performed systematic reviews and meta-analyses on data from 185 prospective studies and 58 clinical trials found that higher intakes of dietary fiber and whole grains provided the greatest benefits in protecting participants from cardiovascular diseases, type 2 diabetes, and colorectal and breast cancers, along with a 15-30 percent decrease in all-cause mortality for those with the highest fiber intakes, compared to those with the lowest (4).

We also see a benefit with fiber and prevention of chronic obstructive pulmonary disease (COPD) in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities (ARIC) study (5). 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 an effect, but it was not as great.

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 receptor negative women (6). This is one of the few studies that has illustrated significant results for this population. Most beneficial studies for breast cancer have shown results in estrogen receptor positive women.

The list of chronic diseases and disorders that fiber prevents and/or treats is continually expanding.

How do I increase my fiber intake?

Emphasize plants on your plate. Animal products don’t contain natural fiber. It’s easy to increase your fiber by choosing bean- or lentil-based pastas, which are becoming easier to find in general grocery stores. Sometimes, they are tucked in the gluten-free section, rather than with wheat pastas. Personally, I prefer those based on lentils, but that’s a personal preference. Read the labels, though; you want those that are made from only beans or lentils and not those that include rice.

If you are trying to prevent chronic diseases in general, aim to consume fiber from a wide array of sources. Ensuring you consume substantial amounts of fiber has several health protective advantages: it helps you avoid processed foods, it reduces your risk of chronic disease, and it increases your satiety and energy levels.

References:

(1) Nutrients. 2020 Oct; 12(10): 3209. (2) USDA.gov. (3) Arch Intern Med. 2011;171(12):1061-1068. (4) Lancet. 2019 Feb 2;393(10170):434-445. (5) Amer J Epidemiology 2008;167(5):570-578. (6) Amer J Clinical Nutrition 2009;90(3):664–671.

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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By David Dunaief, M.D.

Dr. David Dunaief

What is one of the most widely consumed over-the-counter drugs? Would it surprise you to hear that it’s alcohol?

There are many myths surrounding alcohol consumption. For example, you may have heard that Europeans who drink wine regularly live longer because of this. Or that only heavy drinkers need to be concerned about the resulting long-term health impacts. Both have been studied extensively. 

Let’s look at what the research shows.

What’s the relationship between alcohol and cancer risk?

Alcohol is listed as a known carcinogen by the National Toxicology Program of the US Department of Health and Human Services (1). Among the research it details, it lists head and neck, esophageal, breast, liver and colorectal cancers as key cancer risks that are increased by alcohol consumption. Of these, esophageal and breast cancer risks are increased with even light drinking.

The World Health Organization reports that the International Agency for Research on Cancer classified alcohol at the highest level of carcinogen, along with asbestos, radiation, and tobacco (2). 

In a January 2023 New York Times interview with Marissa Esser from the Centers for Disease Control and Prevention, she explained: “When you drink alcohol, your body metabolizes it into acetaldehyde, a chemical that is toxic to cells. Acetaldehyde both ‘damages your DNA and prevents your body from repairing the damage.’” Damaged DNA allows cells to develop into cancer tumors (3).

A meta-analysis of European studies on the effects of light to moderate alcohol use, defined as no more than two standard drinks per day, found that this level of intake caused 23,000 new cancers in the European Union in 2017 (4). Female breast cancer accounted for almost half of these.

These results support an earlier meta-analysis of 113 studies, which found there was a four percent increased risk of breast cancer with daily alcohol consumption of one drink or fewer a day (5). The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increased the risk of breast cancer modestly over a 28-year period (6). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, meaning the more participants drank in a day, the greater their risk increase. In this study, there was no difference in risk by type of alcohol consumed, whether wine, beer or liquor.

Based on what we think we know, if you are going to drink, a drink a few times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes this effect (7).

Does alcohol affect stroke risk?

On the positive side, an analysis of over 83,000 women in the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (8). Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

However, women who consumed more experienced a decline in benefits, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients should not drink alcohol solely to get stroke protection benefits.

If you’re looking for another option to achieve the same benefits, an analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (9). The citrus fruits used most often in this study were oranges and grapefruits. Note that grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (10).

Where does this leave us?

Moderation is the key. It is important to remember that alcohol is a drug, and it does have side effects. The American Heart Association recommends that women drink no more than one glass of alcohol a day. Less is better.

For those at high risk of breast cancer, consider forgoing alcohol.

The stroke benefit is tiny, and in some studies, non-existent. Therefore, it’s better to err on the side of caution and minimize your intake.

If you choose to forgo alcohol, the good news is that there are many more appealing, non-alcoholic beverages on the market than there have been in the past.

References:

(1) cancer.gov. (2) who.int (3) nytimes.com (4) Eur J Public Health. Jun 2021;31(3):591-596. (5) Alc and Alcoholism. 2012;47(3)3:204–212. (6) JAMA. 2011;306:1884-1890. (7) JAMA. 2011;306(17):1920-1921. (8) Stroke. 2012;43:939–945. (9) Stroke. 2012;43:946–951. (10) Medscape.com.

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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Physical inactivity is the greatest risk factor for women over 30

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is still the number one cause of death in the U.S., responsible for one in five deaths (1). 

Many risk factors are obvious, but others are not. Family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking are among the more obvious ones. In addition, age can a role in your risk: men at least 45 years old and women at least 55 years old are at greater risk. Less obvious risks include atrial fibrillation, gout and osteoarthritis. 

In practice, we have more control than we think. You can significantly reduce your risk by making some simple lifestyle changes. How much does lifestyle really affect heart disease risk? Here’s one indicator.

In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events, such as heart attacks (2). Inspired? Let’s take a closer look at different factors.

Does your weight really affect your heart disease risk?

Obesity is always a part of the heart disease risk discussion. How important is it, really?

Results from the Copenhagen General Population Study showed an increased heart attack risk in those who were overweight and in those who were obese – with or without metabolic syndrome, which includes a trifecta of high blood pressure, high cholesterol and high sugar levels (3). “Obese” was defined as a body mass index (BMI) over 30 kg/m², while “overweight” included those with a BMI over 25 kg/m².

Heart attack risk increased in direct proportion to weight. heart attack risk increased 26 percent for those who were overweight and 88 percent for those who were obese without metabolic syndrome.

What does this suggest? Obesity, by itself, without blood pressure, cholesterol or sugar level issues, increases your risk. Of course, those with metabolic syndrome and obesity together were at greatest risk, but without these, your risk is still higher if you’re carrying extra pounds.

How important is physical activity to heart disease risk?

Let’s consider another lifestyle factor, activity levels. An observational study found that these had a surprisingly high impact on women’s heart disease risk (4). Of four key factors — weight, blood pressure, smoking and physical inactivity — lack of exercise was the most dominant risk factor for heart disease, including heart attacks, for those over age 30.

For women over age 70, the study found that increasing physical activity may actually have a greater positive impact on heart disease risk than addressing high blood pressure, losing weight, or even quitting smoking. The researchers noted that women should exercise on a regular basis to most significantly reduce their heart disease risk.

What effect does increasing your fiber have?

Studies show that dietary fiber decreases the risks of heart attack and death after a heart attack. In an analysis using data from the Nurses’ Health Study and the Health Professionals Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (6).

Those who consumed the most fiber had a 25 percent reduction in post-heart attack mortality when compared to those who consumed the least. Even more impressive is that those who increased their fiber intake after a cardiovascular event experienced a 31 percent mortality risk reduction.

The most intriguing part of the study was the dose response. For every 10-gram increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. For perspective, 10 grams of fiber is just over eight ounces of raspberries or six ounces of cooked black beans or lentils.

You can substantially reduce your risk of heart attacks and even potentially the risk of death after sustaining a heart attack with simple lifestyle modifications. Managing your weight, increasing your physical activity and making some updates to your diet can lead to tremendous improvements.

How long do you suffer with osteoarthritis?

Traditional advice for those who suffer from osteoarthritis is that it is best to live with hip or knee pain as long as possible before having surgery. But when do we cross the line and consider joint replacement?

In a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack (5). Those who had surgery for the affected joint saw substantially reduced heart attack risk. If you have osteoarthritis, it is important to improve your mobility, either with surgery or other treatments.

References:

(1) cdc.gov. (2) N Engl J Med. 2000;343(1):16. (3) JAMA Intern Med. 2014;174(1):15-22. (4) Br J Sports Med. 2014, May 8. (5) PLoS ONE. 2014, 9: e91286 (6) BMJ. 2014;348:g2659.

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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Find this recipe for Shrimp, Broccoli and Potato Skewers below. Photo courtesy of Family Features
Offer a mouthwatering array of fruits and veggies with your bbq choices

By David Dunaief, M.D.

Dr. David Dunaief

Independence Day makes me think of fireworks and summer barbecues and picnics. What if you could launch yourself on a journey to better health during these celebratory moments?

I have written about the dangers of processed meats, which are barbecue and picnic staples, and their roles in prompting chronic diseases, such as cancer, diabetes, heart disease and stroke. What if there were appetizing, healthier alternatives?

Green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of fish and olive oil are the foundations of the Mediterranean-style diet. The options are far from tasteless.

I love a family barbecue, and I always strive to have an array of succulent choices. Three-bean salad, mandarin orange salad with mixed greens and a light raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon fillets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable shish kebobs, and large bowl of melons and berries. These drool-worthy buffet items help me keep my health journey on the right path. Let’s look at the scientific evidence that explains why these foods help us.

Preventing cancer

One systematic review provides a comprehensive look at the results of studies that weigh the effects of to a Mediterranean-type diet on cancer risk and progression (1, 2). The authors found an inverse relationship between cancer mortality risk and high adherence to the diet. This means that the more compliant participants were, the lower their risk of cancer mortality.

When comparing the results of high adherence and low adherence to the diet from studies of specific cancers, they identified risk reductions for colorectal, prostate, gastric, and liver cancers (1). Further study also found high adherence reduced the risks of breast, head and neck, gallbladder, and biliary tract cancers (2).

The authors note that, while it’s improbable that any single component of the diet led to these effects, they were able to demonstrate significant inverse correlations between specific food groups and overall cancer risk. For example, the higher the regular consumption of fruits, vegetables, and whole grains, the lower the risk. All three of these fit right in at a summer feast.

Looking closely at specific cancers, another study found that increased consumption of fruits and vegetables may help prevent pancreatic cancer. This is crucial, pancreatic cancer often spreads to other organs before there are symptoms (3). In another study, cooked vegetables showed a 43 percent reduction and non-citrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (4). Interestingly, cooked vegetables, not just raw ones, had a substantial effect.

Preventing and treating diabetes 

Fish might play an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of fish and seafood intake had a substantial decrease in risk of type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood. Therefore, there is nothing wrong with some grilled fish to help protect you from developing diabetes.

Nuts are beneficial in diabetes treatment. In a randomized control trial, mixed nuts led to a substantial reduction of hemoglobin A1C, a very important biomarker for sugar levels for the previous three months (6). They also significantly reduced LDL, bad cholesterol, which reduced the risk of cardiovascular disease.

The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, daily to help treat diabetes?

Preventing a stroke

The Three City study showed that olive oil may have a substantial, protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial.

Though these are promising results, I caution you to use no more than one tablespoon of olive oil per day, since it’s calorically dense. Overindulging can lead to other health problems.

It’s easy to substitute a beneficial Mediterranean-style diet for processed meats, or at least add them to the selection you offer. This plant-rich diet can help you prevent many chronic diseases. 

This Independence Day and beyond, plan to include some delicious, healthy choices for your celebrations.

References:

(1) Curr Nutr Rep. 2016; 5: 9–17. (2) Nutrients. 2017 Oct; 9(10): 1063. (3) Nature. 2010;467:1114-1117. (4) Cancer Causes Control. 2010;21:493-500. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-11. (7) Neurology. 2011 Aug 2;77(5):418-25.

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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Shrimp, Broccoli and Potato Skewers

 Shrimp, Broccoli and Potato Skewers 
Photo courtesy of Family Features

Prep time: 5 minutes
Cook time: 20 minutes
Servings: 4

Ingredients: 

1 pound bagged Little Potatoes
1 bunch broccoli
12 large shrimp, peeled and deveined
1 1/2 lemons, juice only
3 tablespoons fresh thyme, chopped
2 tablespoons olive oil
salt, to taste
pepper, to taste

Directions:

In large, microwave-safe bowl, microwave potatoes on high 5 minutes. Chop broccoli into large pieces. Add broccoli and shrimp to bowl once potatoes are steamed. Add lemon juice, thyme and olive oil; evenly coat potatoes, shrimp and broccoli. Season with salt and pepper, to taste. Build skewers and grill 10-15 minutes on medium-high heat, until shrimp is cooked through.

 

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Soy may reduce breast cancer recurrance. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

A common question in my practice revolves around soy. Should you consumed or avoid it, especially for women who have breast cancer risk factors? It is a valid question, and the medical research has begun to debunk the myth that soy is detrimental. The form of soy is important; soy from food seems to be safe, but soy in high supplement form has shown mixed results.

Why are patients worried? Soy contains phytoestrogens (plant estrogens). The thought is that phytoestrogens have similar effects as estrogen produced by humans or other animals. However, the story is complex: soy may actually help prevent breast cancer and its recurrence. It may also have other positive health effects. In some cellular and animal studies, high doses of isoflavones or isolated soy protein stimulate cancer growth (1). 

Further research shows that these findings don’t translate to humans, most likely because humans metabolize these differently.

Breast Cancer

The Shanghai Breast Cancer Survival Study, an over 5,000 patient observational trial that followed patients for a median of 3.9 years, has had resounding effects on the way we think of soy in relation to breast cancer. The population consisted of women who had already had one occurrence of breast cancer that was in remission. The women who consumed the most soy from food, measured as soy isoflavones or soy proteins, had a 32 percent reduction in a second occurrence of breast cancer and a 29 percent reduction in breast cancer mortality, compared to those who consumed the least (2).

This inverse relationship was seen in both estrogen receptor-positive and estrogen receptor-negative women. It is more difficult to treat estrogen receptor-negative women; therefore, making these results even more impressive.

One prospective study followed over 6,000 women in the U.S. and Canada. It found that women who ate the highest amounts of soy isoflavones had a 21 percent lower risk of death compared with women with the lowest intakes (3). The Shanghai Women’s Health Study followed 73,223 Chinese women for more than 7 years and was the largest study of soy and breast cancer risk in a population with high soy consumption (4). It found that women who ate the most soy had a 59 percent lower risk of premenopausal breast cancer compared with those who ate the lowest amounts of soy. There was no association with postmenopausal breast cancer.

The study authors published a follow-up analysis from the same cohort seven years later to evaluate any association between soy foods and specific types of breast cancer, breaking out the results by type (5). In all cases, risk was lower with higher soy intakes.

Menopause

Soy and soy isoflavones may help improve cognitive function in postmenopausal women. This effect was seen only in women who increased their soy intake before age 65. There may be a “critical window” of therapeutic opportunity in early stages of post-menopause where soy has the greatest impact on cognitive function (6).

Soy is not the food with the greatest phytoestrogens, flaxseed is. In a randomized control trial, a daily flaxseed bar did no better at reducing vasomotor symptoms in postmenopausal women, such as hot flashes, than a fiber placebo bar. This took the study’s authors by surprise; preliminary studies had suggested the opposite (7). Reinforcing these results, another randomized controlled trial failed to show any beneficial effect of soy isoflavones on menopausal symptoms or on preventing bone loss (8). 

Lung Cancer

Soy isoflavones help to boost the effect of radiation on cancer cells by blocking DNA repair in these cells (9). They also protect surrounding healthy cells with an antioxidant effect. Soybeans contain three powerful components, genistein, daidzein and glycitein, that provide this effect. Pretreating lung cancer patients may promote better outcomes.

The risk of lung cancer was also shown to be reduced 23 percent in one meta-analysis of 11 trials (10). In subset data, when analysis was restricted to the five highest quality studies, there was an even greater reduction: 30 percent.

Cholesterol Levels

Soy may have modest effects in reducing cholesterol levels. Interestingly, people who convert a soy enzyme to a substance called equol, an estrogen-like compound, during digestion were considered the only ones to benefit; however, one study showed that equol non-producers also benefited with a reduction in LDL “bad” cholesterol (11). The equol producers maintained their HDL “good” cholesterol whereas the non-producers saw a decline.

What does all of this tell us? Soy is most likely beneficial for men and women alike, even in those with a risk of breast cancer. It does not mean we should eat a soy-based diet, but rather have soy in moderation – on a daily basis, perhaps. It is best to eat whole soy, not soy isolates. Also, soy supplements are not the same as foods that contain soy, so it is best to consume soy in food form.

References:

(1) Cancer Research. 2001 Jul 1;61(13):5045-50. (2) JAMA. 2009;302(22):2437-2443. (3) Cancer. 2017 Jun 1;123(11):2070-9. (4) Am J Clin Nutr. 2009 Apr 29;89(6):1920-6. (5) Int J of Cancer. 2016 Aug 15;139(4):742-8. (6) Obstet Gynecol. 2011;18:732-753. (7) Menopause. 2012 Jan;19(1):48-53. (8) Arch Intern Med. 2011;171:1363-1369. (9) J Thorac Oncol. 6(4):688-698, April 2011. (10) Am J Clin Nutr. 2011 Dec;94(6):1575-83. (11) Am J Clin Nutr. March 2012 vol. 95 no. 3 564-571.

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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Call 911 at the first sign of a heart attack. METRO photo

By David Dunaief, M.D.

One person every 40 seconds: that’s how prevalent heart attacks still are in the U.S. (1). Your gender and race don’t matter, we’re all susceptible. Of these 805,000 annual heart attacks, one in five is “silent” — you might not be aware you’ve had it, but your body is still affected. The good news is that your potential outcomes are significantly better if you recognize the symptoms while having a heart attack and receive immediate medical attention.

What are heart attack symptoms?

The most recognizable symptom is chest pain. However, there are an array of more subtle symptoms, such as discomfort or pain in the neck, back, jaw, arms and upper abdominal areas. You might also experience nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate). Unfortunately, most people don’t recognize these as symptoms of heart attack (2). According to one study, about 10 percent of patients present with atypical symptoms and no chest pain (3).

Are heart attack symptoms really different for men and women?

There has been much discussion about whether men and women have different symptoms when it comes to heart attacks. What does the research tell us?

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish study of 54,000 heart attack patients, one-third were women.  After having a heart attack, a significantly greater number of women died in the hospital or near-term when compared to men. The women received aggressive treatments, such as reperfusion therapy, artery opening treatment that includes medications or invasive procedures, less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram.

One theory about why women receive less aggressive treatment when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. Is this true? Not according to studies.

In one observational study of 2,500 patients, results showed that, though there were some subtle differences, when men and women presented with chest pain as the main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: the duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. The population difference was a conspicuous weakness of an otherwise solid study, since age and previous heart attack history are important factors.

In the GENESIS-PRAXY study, another observational study, the median age of both men and women was 49. Results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings, significantly more were women than men.

Those who did not have chest pain symptoms may have experienced back discomfort, weakness, discomfort or pain in the throat, neck, right arm and/or shoulder, flushing, nausea, vomiting and headache. If the patients did not have chest pain, regardless of sex, the symptoms were diffuse and nonspecific. 

Some studies imply that up to 35 percent of patients do not present with chest pain as their primary complaint (7).

Is someone having a heart attack?

Call 911 immediately, and have the patient chew an adult aspirin (325 mg) or four baby aspirins, provided they do not have a condition that precludes taking aspirin. The purpose of aspirin is to thin the blood quickly, but not if the person might have a ruptured blood vessel. The 911 operator or emergency medical technician who responds can help you determine whether aspirin is appropriate.

Don’t hesitate to seek immediate medical attention; it’s better to have a medical professional rule out a heart attack than to ignore one.

The most frequently occurring heart attack symptoms

Most patients have similar types of chest pain, regardless of gender. However, this is where the complexity begins. The percentage of patients who present without chest pain seems to vary depending on which study you review — ranging from less than 10 percent to 35 percent.

Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. It’s important to recognize heart attack symptoms, since quick action can save your life or a loved one’s.

References:

(1) csc.gov. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA. 2012;307:813-822.

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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