Authors Posts by David Dunaief

David Dunaief

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Trump's diet has been brought to the forefront during this election year.

By David Dunaief, M.D.

Donald Trump could learn a thing or two from Bill Clinton. No, we are not talking about politics; we are talking about health. Trump is a public persona, and his diet has been brought to the forefront. As was Clinton’s when he was the United States’ 42nd president. An Aug. 8 New York Times article discussed Trump’s love for fast food and his ironic obsession with cleanliness (1).

Trump’s approach to diet seems to be eerily similar to the standard American diet — with the added detriment of fast food. Though he likes the cleanliness of fast food chains, his arteries may not like the “dirtying” effect of atherosclerosis, or arterial plaques.

Admittedly, I don’t know anything about his family history, including whether or not cardiovascular disease is an issue; nor his blood chemistries, such as cholesterol levels; nor whether or not he has high blood pressure. However, one thing is clear: He is overweight with a significant amount of visceral fat, or belly fat. This type of body fat is considered the most dangerous because it surrounds the internal organs such as the heart (2). This promotes potential cardiovascular disease and diabetes.

For a long time, Bill Clinton also had a love for fast food and the standard American diet. However, this resulted in atherosclerosis, which caused significant blockage of coronary arteries and resulted in coronary artery bypass surgery involving four arteries in 2004. Since then, he has been on a mission to reform his diet. Through the influence of physicians like Drs. Dean Ornish and Caldwell Esselstyn, both advocates of plant-based diets, Clinton has done much better and lost significant weight, as well.

Thus, this is more about the standard American diet, with its high saturated fat, high sugar, refined grains, processed meats and elevated salt versus the nutrient-dense, more likely plant-based, approach with fruits, vegetables and whole grains and their respective effects on cardiovascular disease, atherosclerosis and even mortality.

These type of plant-based diets include the Mediterranean-type diet, the DASH diet, the Ornish diet and the Esselstyn diet.

If we look solely at the differences between saturated fats and unsaturated fats, a recent study involving over 120,000 participants showed that when just 5 percent of pure saturated fats in the diet were replaced with unsaturated fats, this resulted in a significant reduction in all-cause mortality of up to 27 percent over 32 years (3). For more details on this study analysis, see my recent article, “Let the dietary fat wars begin,” which can be found online at www.tbrnewsmedia.com.

I am a firm believer in leading by example. I think it is a powerful way to get patients to follow through with lifestyle changes, especially diet and exercise. That is why the dietary changes I ask my patients to make, I also have been following for years.

Data on cardiovascular disease

Recently, the Centers for Disease Control and Prevention released data about cardiovascular disease that is downright depressing. From 2000 to 2010, the risk of dying from this disease was decreasing by almost 4 percent a year in both men and women (4). However, from 2010 to 2014, this decrease slowed precipitously to 0.23 percent in men and 1.17 percent in women. The reason for this slowdown is that we may have reached a ceiling in the effectiveness of traditional medical interventions. The suggestions are that we concentrate more efforts on lifestyle modifications, specifically diet, physical activity and not smoking.

At the same time, 2011-2012 NHANES data showed a significant increase in obesity and diabetes (5). The bad news is we have not changed our lifestyles enough, especially diet. The good news is that there is a large upside for change and progress!

Reversing heart disease

This research includes both Ornish and Esselstyn. Both physicians have shown it is possible, through a plant-based approach, to have a significant impact on cardiovascular disease, reversing atherosclerosis and preventing a cardiovascular event such as a heart attack.

Esselstyn’s research includes a small study with 24 of his own patients (6). Of these, 18 patients completed the five-year study. These 18 patients had experienced 49 cardiovascular events in the previous eight years. Results show that with a plant-based diet, none of the 18 had a cardiovascular event. Eleven patients chose to have angiographic analysis to determine stenosis, or blockage. None of the 11 progressed; in fact, eight showed regression in atherosclerosis.

Though this was a small study with no control group, the duration, the reversal of atherosclerosis at the study end point and the severity of cardiovascular disease prior to the study make these results intriguing and impressive.

This study was extended to 12 years with similar results and only one additional patient dropping out. Interestingly, those who discontinued the study had a subsequent total of 13 cardiovascular events. One of the key study markers was keeping total cholesterol to lower than 150 mg/dL. The diet emphasized fruits, vegetables, beans, legumes and whole grains.

Then, Esselstyn’s group looked at 198 patients with cardiovascular disease (7). The results were similar to the smaller initial study, with those in the adherent group following a nutrient-dense, plant-based diet experiencing a most astonishing cardiovascular event rate of only 0.6 percent, while the 21 who were nonadherent (the unbeknownst control group, per se) experienced an event rate of 62 percent over 3.7 years.

What about Ornish’s research? Not surprisingly, the results were very similar to Esselstyn’s. In the Ornish study, results showed a reversal in atherosclerosis of 7.9 percent in the treatment group compared to baseline, whereas those in the control arm over the same period showed a 27.7 percent increase in atherosclerosis or plaques in the arteries (8). Also, the control group experienced more than two times as many cardiovascular events as seen in the treatment group. The patients in the treatment group were on a plant-based diet.

There were 48 patients with moderate to severe cardiovascular disease at the beginning of the study, with 28 patients in the treatment group and 20 assigned to the control arm. Of these patients about 75 percent in each group completed the study. The duration of the study was five years. Again, these results are intriguing, and each study reinforces the others.

A clinical example

In my practice, I recently had a 69-year-old white male patient with cardiovascular disease and an extensive family history of the disease, who went to the cardiologist prior to working with me. The initial carotid Doppler (sonogram of the neck arteries) showed a 16 to 50 percent blockage in both carotid arteries. After a year, the carotid Doppler results had been reduced to between 1 and 15 percent blockages in both carotid arteries. The patient’s total cholesterol had dropped to 146 mg/dL, and this result included discontinuing his cholesterol medication, though it was not a statin. Of course, this is anecdotal, but it is consistent with the results mentioned in the studies above.

In conclusion, now you see why Bill Clinton followed the advice of at least two very wise physicians after his quadruple bypass surgery. Lifestyle with a nutrient-dense, plant-based diet not only can prevent cardiovascular disease but may be able to arrest and even reverse plaques in the arteries. Trump would be wise to follow suit and focus on cleanliness of his arteries rather than just cleanliness of the restaurant, as we all would.

References: (1) NYTimes.com. (2) Crit Pathw Cardiol. 2007;6(2):51-59. (3) JAMA Intern Med. 2016;176(8):1134-1145. (4) JAMA Cardiol. online June 29, 2016. (5) cdc.gov/nchs/nhanes. (6) J Fam Pract. 1995;41(6):560-568. (7) J Fam Pract. 2014;63(7):356-364b. (8) JAMA. 1998;280(23):2001-2007.

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

Consider monitoring blood pressure on both arms. Stock photo

This week, I’d like to discuss some of the nuances of hypertension, or high blood pressure, a contributing risk factor for heart disease. Hypertension affects approximately 33 percent of Americans, according to the latest statistics from the Centers for Disease Control and Prevention, and only 52 percent of these have it controlled (1). What could we possibly learn about blood pressure that we have not heard already? New information is always coming out about this common disease. Studies are teaching us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. Let’s look at the evidence.

Technique

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms, and when one of my longtime patients asked me why, I joked that I need to practice. In truth, it’s because there may be significant benefit from taking readings in both arms.

An analysis of the Framingham Heart Study and Offspring Study showed that when the blood pressure was taken in both arms, when there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease (2).

This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.

So, the next time you go to the doctor’s office, you might want to ask if they would take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Timing

When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (3). This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.

Twenty-four ambulatory blood pressures readings were taken with these patients, which means these were standardized readings. Does this mean that nighttime readings are more important? Not necessarily, but it is an interesting finding. With my patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. However, at least one of the readings should be taken before antihypertensive medications are taken, since these will alter the readings.

Salt impact

There has always been a debate about whether salt really plays a role in high blood pressure and heart disease. The latest installment in this argument is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (4). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

The graphs of sodium reduction mimicked the line graphs for the reductions in deaths from stroke and heart disease. One potential study weakness was that physical activity was not taken into account. However, a strength of this study was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods that we least suspect, such as breads, pastas and cheeses.

Age-related macular degeneration

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, those patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (5). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics, and angiotensin receptor blockers.

However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. In addition, another study actually suggests the opposite — that blood pressure medications may reduce the risk of AMD (6). However, this was a retrospective (backward-looking) study, and it has yet to be published.

This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Fall risk

As we age, falling risk seems to increase. One study shows that blood pressure medications significantly increase fall risk in the elderly (7). Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.

References: (1) CDC.gov/blood pressure. (2) Am J Med. 2014 Mar;127(3):209-215. (3) J Am Soc Hypertens 2014;8:e59. (4) BMJ Open 2014;4:e004549. (5) Ophthalmology online April 30, 2014. (6) ARVO 2013 Annual Meeting: presentation. (7) JAMA Intern Med. 2014;174(4):588-595.

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

The types, quantity and quality of dietary fat all matter. Stock photo

Dietary fat is one of the most controversial and complicated topics in medicine. Experts have debated this topic for years, ever since we were told that a low-fat diet was important. There are enumerable questions, such as: Is a high-fat diet good for you? What about low-fat diets? If this is not enough, what type of fats should we be consuming?

There are multiple types of fats and multiple fat sources. For instance, there are saturated fats and unsaturated fats, which include monounsaturated and polyunsaturated. There are also trans fats, which are man-made. However, there are several things that we can agree on, like we need fat since the brain is made of at least 60 percent fat (1), and trans fats are downright dangerous. Trans fats are the Frankenstein of fats; anything created in a lab when it comes to fats is not a good thing.

How have we evolved in the fat wars? Originally we were told that a low-fat diet was beneficial for heart disease and weight loss (2). This started in the 1940s but gained traction in the 1960s. By the 1980s, everyone from physicians to the government to food manufacturers was exclaiming about a low-fat diet’s benefits for overall health. But did they go too far trying to make one size fit all? The answer is a resounding YES!!

There are only three macronutrients: fats, carbohydrates and protein. Declaring that one of the three needed to be reduced for everyone did not have the results we wanted or expected. Americans were getting fatter, not thinner, heart disease was not becoming rare, and we were not becoming healthier.

Some fats more equal than others

The biggest debate recently has been over the amount of fats and saturated fats. The most recent 2015-2020 Dietary Guidelines for Americans do not limit the amount of fat, but do limit the amount of saturated fat to less than 10 percent of our diet (3). Does this apply to everyone? Not necessarily. Remember, it is very difficult to apply broad rules to the whole population.

However, the most recent research suggests that foods containing pure saturated fats are not useful, may be detrimental, and at best are neutral. Meanwhile, poly- and monounsaturated fats are potentially beneficial. You will want to read about the most recent study below.

Sources of fat

Pure saturated fats generally are found in animal products, specifically dairy and all meats. The exception is fish, which contains high levels of polyunsaturated fats. Interestingly, most foods that contain predominantly unsaturated fats have saturated fat as well, though the reverse is not typically true. There are also saturated plant oils, like coconut and palm. Processed foods also have saturated fats. Potentially beneficial polyunsaturated fats include fatty fish and some nuts, seeds and soybeans, while potentially beneficial monounsaturated fats are olive oil, avocados, peanut butter, some nuts and seeds (4). Let’s look at the research.

Saturated fat

takes a dive In the ongoing battle over saturated fats, the latest research suggests that it is harmful. In recent well-respected combined observational study (The Nurses’ Health Study and Health Professional Follow-up Study), results show that replacing just 5 percent of saturated fat with poly- or monounsaturated fats results in significant reductions in all-cause mortality, 27 and 13 percent, respectively (5). There were also significant reductions in neurodegenerative diseases, which include macular degeneration, Parkinson’s, Alzheimer’s and multiple sclerosis.

However, when reduced saturated fats were replaced with refined grains, there was no difference in mortality. There were over 126,000 participants with an approximate 30-year duration. Also, the highest quintile of poly- and monounsaturated fat intake compared to lowest showed reductions in mortality that were significant, 19 and 11 percent, respectively. Not surprisingly, trans fat increased the risk of mortality by 13 percent.

The polyunsaturated fats in this study included food such as fatty fish and walnuts, while the monounsaturated fats included foods such as avocado and olive oil. Eating fish had the modest reductions in mortality, 4 percent. The authors suggest replacing saturated fats with healthy poly- and monounsaturated fats that are mostly plant-based, but not with refined grains or trans fat.

Previous study showed neutrality

This was a meta-analysis (a group of 72 heterogeneous trials, some observational and others randomized controlled trials), with results showing that saturated fats were neither harmful nor beneficial, but rather neutral (6).

However, there were significant study weaknesses. The researchers may have used foods that include both saturated fats and unsaturated fats. This is not a pure saturated fat comparison. What did those who had less saturated fat eat instead — refined grains, maybe? Also, the results in the study’s abstract partially contradicted the results in the body of the study. Thus, I would pay a lot more attention to the above study than to this one. Again, though, even the best outcomes for saturated fats in this study did not provide a beneficial effect.

What about butter?

In a meta-analysis (group of nine observational studies), results showed that butter was neither beneficial nor harmful, but rather neutral in effect (7). Then is it okay to eat butter? Not so fast! Remember, the above study showed that saturated fat was potentially harmful, and butter is pure saturated animal fat. Also, there are study weaknesses. It is not clear what participants were eating in place of butter, possibly refined grains, which would obfuscate the potential harms. It was also unclear whether there were poly- and monounsaturated fats in the diet and what effect this might have on making butter look neutral.

Unearthing a saturated fat study

In a randomized controlled trial (Minnesota Coronary Experiment), this one from 1968 to 1973 and not fully analyzed until recently, results showed that polyunsaturated fat from corn oil, compared to a diet with higher saturated fat, reduced cholesterol level while increasing the risk of mortality (8).

The researchers expected the opposite result. Is this a paradox? Fortunately, no! Corn oil is used in processed foods and has a high amount of inflammatory omega-6 fatty acids that may negate the positive results of reducing cholesterol. Plus, the patients were only consuming the corn oil for a short 15-month period, which is unlikely to be long enough to show beneficial effects on mortality.

The bottom line is this: It’s not about low-fat diets! Saturated fats have not shown any benefits, and could be potentially harmful, but at best, they are neutral. However, foods that contain high amounts of poly- or monounsaturated fats that are mostly plant-based have shown significant benefit in reducing the risk of death and neurodegenerative diseases.

However, there are several caveats. Not all unsaturated fats are beneficial. For instance, some like corn oil may contain too many omega-6 fatty acids, which could contribute to inflammation. Also, replacing saturated fats with carbohydrates, especially refined grains, does not improve health. I told you fats are not easy to understand. It can be helpful to change our perception of fats: They are not “good and bad.” Instead, think of them as “useful and useless.” For our health, we should be focused on the “useful.”

References: (1) Acta Neurol Taiwan. 2009;18(4):231-241. (2) J Hist Med Allied Sci 2008;63(2):139-177. (3) health.gov/dietaryguidelines/2015. (4) https://www.heart.org. (5) JAMA Intern Med. 2016;176(8):1134-1145. (6) Ann Intern Med. 2014;160(6):398-406. (7) PLoS ONE 11(6):e0158118. (8) BMJ 2016;353:i1246.

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

Exercise is important in reducing the risk of fractures. Stock photo

By David Dunaief, MD

Osteoporosis is a complex disease. For one thing, it progresses with no symptoms, until the more severe stage of fractures that cause potential disability and increase mortality. For another, the only symptoms are from the treatment with medications, better known as side effects. Third, lifestyle modifications and supplements, while important, require adherence to a regimen.

I am not a big advocate of medication, as I am sure you have gathered from my previous articles; however, medication does have its place. There are studies that show benefit from the two main classes for osteoporosis, bisphosphonates such as alendronate (Fosamax, though it is now generic) and the newer class that involves monoclonal antibodies such as denosumab (Prolia). And, of course, I am a big advocate of lifestyle modifications including diet, exercise, smoking cessation and even some supplements. The side effects of these modifications are better health outcomes for chronic diseases and disorders in general. What I can’t advocate for, as a physician sworn to help people, is the new emerging cohort that I refer to as the “do-nothing group.”

Recently, a New York Times article on June 1, 2016, entitled, “Fearing Drugs’ Rare Side Effects, Millions Take Their Chances With Osteoporosis,” reported that prescriptions for medications to treat the disease have fallen by more than 50 percent from 2008 to 2012 because of the fear of the side effect profile that include rare instances of atypical fractures and jawbone necrosis (1).

In the article, one doctor mentions that patients prefer diet and exercise, but that it does not work. Well, he may be partially correct. Diet and exercise may not work if they’re not implemented. However, if people actually make lifestyle modifications, there could be substantial benefit. Just to give up on the medications for osteoporosis or to refuse to take them is not going to improve your chances or reduce your risk of getting fractures in the spine, hip, wrist or other locations. In other words, the “do-nothing” approach won’t help and may significantly increase your risk of fracture and other complications, such as death.

At the top of the list of risk factors for osteoporosis is nontraumatic fractures — in other words, breaking of bone with low-impact events. In this case, once you have had a fracture, the probability of having a recurrent or subsequent fracture increases more than three times in the first year, according to a recent Icelandic study (2). Lest you think that you are in the clear after a year since your first fracture: After 10 years, the risk of subsequent fracture still remains high, with a twofold increased risk.

Osteoporosis involves bone loss. We typically measure this through the bone mineral density (BMD) biomarker using a DXA scan. However, another component is bone quality. Sarcopenia, or loss of lean muscle mass, may play a role in bone quality. There are vitamins, such as vitamin K2, that can have beneficial effects on bone based on bone quality as well. No, this is not the same as the more well-known vitamin K1 used in clotting, which may also have a smaller benefit in preserving bone.

Let’s look at the evidence.

Avoiding sacropenia

Sarcopenia is a fancy word for a depressing phenomenon that occurs as we age and become more and more sedentary; it is the loss of lean skeletal muscle mass at the rate of 3 to 8 percent each consecutive decade after 30 and also loss of strength (3). It may have significant effects on about one-third of those over age 60 and half of those over 80. Unless, of course, you are physically active on a regular basis. In the Study for Osteoporotic Fractures in Men, results show that sarcopenia plus osteoporosis, taken together, increases the risk of fracture more than three times in older men (4).

The researchers assessed muscle wasting by using the European Working Group on Sarcopenia in Older Patients (EWGSOP), which takes into account weakness (grip strength <20 kg for men), slowness (walking=0.8 m/s) and low lean muscle mass (< 20 percent). This involved over 5,000 men with a mean age of about 74. The group with sarcopenia had significantly lower grip strength and was less physically active. In another study, those who were healthy 65-year-old adults who had sarcopenia or low lean muscle mass were at a greater than two times risk of experiencing a low-trauma fracture within three years (5). This was according to the EWGSOP1 cutoff criteria for sarcopenia.

Preventing sarcopenia

Well, beyond the obvious of physical activity and formal exercise, there is a medication that has potentially shown positive results. This is the bisphosphonate alendronate (Fosamax). In a study, results showed that alendronate increased muscle mass significantly over a one-year period (6). In the appendicular (locomotive) skeletal muscle, there was a 2.5 times increase in muscle mass, while in lower limb muscle mass there was a greater than four times increase. This was a retrospective (backward-looking), case-control study involving about 400 participants. While these results are encouraging, we need a prospective (forward-looking), randomized controlled trial. For those who don’t want to or can’t for some reason exercise, then medication may help with muscle mass.

Exercise! Exercise! Exercise!

In a meta-analysis (a group of 10 trials), results showed there was a significant 51 percent reduction in the risk of overall fracture in postmenopausal women who exercised (7). This study involve over 1,400 participants. Does exercise intensity matter? Fortunately, the answer is no. If you like jogging or running, that’s great, but walking was also beneficial. This is important, since you want to do the type of activity that is more enjoyable to you, especially since the benefit of exercise dissipates when you stop doing it regularly (8).

The importance of K2

In a recent study, vitamin K2 was shown to reduce the risk of hip fracture by 60 percent, vertebral fracture by 77 percent and nonvertebral fractures by a whopping 81 percent (9). According to the authors, this benefit may be derived from bone strength (BMC, or bone mineral content) rather than from bone mineral density (BMD). There were 325 postmenopausal women in this study. It was a randomized controlled trial with one group receiving vitamin K2 (MK-4, menatetrenone) supplementation of 45 mg/day and the other a placebo group.

Don’t forget fruits and vegetables

In the Singapore Chinese Health Study, a prospective population-based study, results showed that there was a 34 percent reduction in the risk of hip fracture in the highest quintile of vegetable-fruit-soy (VFS) intake, compared to the lowest quintile (10). This study involved over 63,000 men, premenopausal and postmenopausal women with an age range from 45 to 74 years old. The results showed a dose-dependent curve, meaning the more VFS, the higher the reduction in hip fracture risk. Interestingly, there was no difference in risk of fracture when meat in the form of meat dim-sum was used instead of plant-based protein. The researchers concluded that an Asian plant-based diet may help reduce the risk of hip fracture. I’m not saying to take medications for osteoporosis, but you need to do something — either medications, lifestyle modifications, supplements or all three — especially if you have a history of low-trauma fractures, because your risks of disability, complications and death increase significantly with subsequent fractures. But, do not be part of the growing “do-nothing” group.

References:

(1) J Bone Miner Res. 2015;30(12):2179-2187. (2) World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases 2016. Abstract 0C35. (3) Curr Opin Clin Nutr Metab Care. 2009; 12(1):86–90. (4) American Society of Bone and Mineral Research 2013. Abstract 1026. (5) Age Ageing.2010;39:412-423. (6) Osteoporos Sarcopenia. 2015;1(1):53-58. (7) Osteoporos Int. 2013;24(7):1937. (8) Ann Intern Med. 1988;108(6):824. (9) Osteoporos Int. 2007;18(7):963-972. (10) J Nutr. 2014;144(4):511-518.

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

Iron is important for exercise motivation and may play a role in peak mental functioning. Stock photo

I believe the most salient teaching point in medical school and beyond was when a professor explained, as it relates to the patient diagnosis, when you hear hooves think horses not zebras. What this means is think of the more common or more likely diseases or disorders in a differential diagnosis rather than the more esoteric or rare diseases. And when a patient presents with fatigue, one of the more common reasons is iron deficiency.

Major causes of low iron are anemia of chronic disease, iron deficiency anemia, sideroblastic anemia and thalassemia. Of these, iron deficiency anemia is the most common. However, there is a much less known, but not uncommon, form of low iron. This is called iron deficiency without anemia. Unlike iron deficiency anemia, the straightforward CBC (complete blood count) that is usually drawn cannot detect this occurrence since the typical indicators, hemoglobin and hematocrit, are not yet affected.

So how do we detect iron deficiency without anemia? Not to despair, since there is a blood test done by major labs called ferritin. What is ferritin? Ferritin is a protein that is involved in iron storage. When ferritin is less than 10 to 15 ng/ml, the diagnosis of iron deficiency is most likely indicated. Even healthy people with ferritin slightly higher than this level may also have iron deficiency (1). The normal range of ferritin is 40-200 ng/ml.

At this point, you should be asking who does low ferritin affect and what are the symptoms? Women and athletes are affected primarily, and low ferritin levels may cause symptoms of fatigue. It is also seen with some chronic diseases such as restless leg syndrome (RLS) and attention deficit hyperactivity disorder (ADHD) in children.

Effect on women

In a prospective (forward-looking) study done in 1993 looking at primary care practices, it was determined that 75 percent of patients complaining of fatigue were women (2). Interestingly, less than 10 percent of these women had abnormal lab results when routine labs were drawn, most probably without a ferritin level. Many of them had experienced these symptoms for at least three months.

There was a randomized controlled trial (RCT), the gold standard of studies, that showed women who were suffering from fatigue and low or low-normal ferritin levels (less than 50 ng/ml), but who did not have anemia, benefited from iron supplementation (3). When comparing women with these ferritin levels, many of those who were given 80 mg of oral prolonged release ferrous (iron) sulfate supplements daily saw a significant improvement in their fatigue symptoms when compared to those women who were not given iron. Almost half the women taking iron supplements had a significant improvement in fatigue symptoms. The results were seen in a very short 12-week period. This is nothing to sneeze at, since fatigue is one of main reasons people go to the doctor. Also, although this was a small study, there were 198 women involved, ranging from 18 to 53 years old.

There are caveats to these study results. There was no improvement in depression or anxiety symptoms, nor in overall quality of life. Even though it was blinded, stool changes occur when a patient takes iron. Therefore, the women taking supplements may have known. Nonetheless, the study results imply that physicians should check ferritin level, not only a CBC, when a premenopausal woman complains of fatigue. Note that all of the women in the study were premenopausal. This is important to delineate, since postmenopausal women are at much higher risk of iron overload, rather than deficiency. They are no longer menstruating and therefore do not rid themselves of significant amounts of iron.

Athletes

According to an article in The American Journal of Lifestyle Medicine, athletes’ endurance may be affected by iron deficiency without anemia (4). Low ferritin levels are implicated, as in the previous study. Iron is important for exercise motivation and may play a role in peak mental functioning, as reported in “Iron: Nutritional and Physiological Significance.” In animal studies, iron deficiency without anemia is associated with reduction in endurance because of a decrease in oxygen-based enzymatic activity within the cells.

However, this has not been shown definitively in human athletes and remains an interesting, but yet to be proven, hypothesis. Interestingly, female endurance athletes are more likely to be affected by iron deficiency without anemia, which occurs in about 25 percent of this population, according to studies (5). Low ferritin is not seen as much in male athletes. This difference in gender may be due to the fact that women not only menstruate, losing iron on a regular basis, but also their intake of dietary iron seems to be lower (6).

However, male athletes are not immune. At the end of the season for high school runners, 17 percent had iron deficiency without anemia (7). Do not take iron supplements without knowing your levels of hemoglobin and ferritin and without consulting a doctor. Studies are mixed on the benefits of iron supplementation without anemia for athletes.

Impact on restless leg syndrome

Iron deficiency with a ferritin level lower than 50 ng/ml affects approximately 20 percent of patients who suffer from restless leg syndrome (8). Restless leg syndrome, classified as a neurologic movement disorder, causes patients to feel like they need to move their legs, most commonly about a half-hour after going to bed. In a very small study, patients with restless leg syndrome who had ferritin levels lower than 45 ng/ml saw significant improvement in symptoms within eight days with iron supplementation (9).

Before you get too excited, the caveat is that 75 percent of restless leg patients have high ferritin levels. It is impressive in terms of being an easy fix for those who have low ferritin levels. And, it may be that high ferritin levels in RLS has the same symptoms as low ferritin for this is the case when it comes to iodine levels in hypothyroid patients. Iron is a trace mineral, meaning we only need small amounts to maintain proper levels.

Ferritin levels — both high and low — may play a role in a number of diseases and symptoms. If you are suffering from fatigue, a CBC test may not be enough to detect iron deficiency. You may want to suggest checking your ferritin level. Though iron supplementation may help those with symptomatic iron deficiency without anemia, it is very important not to take iron supplements without the direct supervision of your physician.

References: (1) Br J Haematol. 1993;85(4):787-798. (2) BMJ 1993;307:103. (3) CMAJ. 2012;184(11):1247-1254. (4) Am J Lifestyle Med. 2012;6(4):319-327. (5) J Am Diet Assoc. 2005;105:975–978. (6) J Pediatr. 1989;114:657–663. (7) J Adolesc Health Care. 1987;8:322–326. (8) Am Fam Physician. 2000;62(4):736. (9) Sleep Med. 2012;13(6):732-735. Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. Stock photo

By David Dunaief, MD

Most of us have experienced a difficult night’s sleep. However, those with obstructive sleep apnea (OSA) may experience a lack of restful sleep much more frequently.

OSA is an abnormal pause in breathing while sleeping that occurs at least five times an hour. There are a surprising number of people in the United States who have this disorder. The prevalence may be as high as 20 percent of the population, and 26 percent are at high risk for the disorder (1). There are three levels of OSA: mild, moderate and severe.

The risk factors for OSA are numerous and include chronic nasal congestion, large neck circumference, being overweight or obese, alcohol use, smoking and a family history.

Not surprisingly, about two-thirds of OSA patients are overweight or obese. Smoking increases risk threefold, while nasal congestion increases risk twofold (2). Fortunately, as you can see from this list, many of the risk factors are modifiable.

The symptoms of OSA are significant: daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration and morning headaches. These symptoms, while serious, are not the worst problems. OSA is also associated with a list of serious complications, such as cardiovascular disease, high blood pressure and cancer.

There are several treatments for OSA. Among them are continuous positive airway pressure — known as CPAP — devices; lifestyle modifications, including diet, exercise, smoking cessation and reduced alcohol intake; oral appliances; and some medications.

Cardiovascular disease

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

Not to leave out men, another observational study showed similar risks of cardiovascular disease with sleep apnea and benefits of CPAP treatment (4). There were more than 1,500 men in this study with a follow-up of 10 years. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in stemming 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 38 and 125 percent, respectively (5). But, just like 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.

Though all three studies were observational, it seems that OSA affects both genders and all ages when it comes to increased risk of cardiovascular disease and death, and CPAP may be effective in reducing these risks.

Cancer association

In sleep apnea patients under 65 years old, a study showed an increased risk of cancer (6). The authors believe that intermittent low levels of oxygen, which are caused by the many frequent short bouts of breathing cessation during sleep, may be responsible for the development of tumors and their subsequent growth.

The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. So, for those patients with more than 12 percent low-oxygen levels at night, there is a twofold increased risk of cancer development, when compared to those with less than 1.2 percent low-oxygen levels.

Sexual function

It appears that erectile dysfunction may also be associated with OSA. CPAP may decrease the incidence of ED in these men. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspect of this study was that, at baseline, the participants were overweight — not obese — on average and were young, at 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half 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.

Dietary effect

Although CPAP can be quite effective, as shown in some of the studies above, it may not be well tolerated by everyone. In some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or may be used in combination with CPAP.

In a small study, a low-energy diet showed positive results in potentially treating OSA. It makes sense, since weight loss is important. But even more impressively, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year. Patients studied were those who suffered from moderate-to-severe levels of sleep apnea. Low-energy diet implies a low-calorie approach. A diet that is plant-based and nutrient-rich would fall into this category. One of my patients who suffered from innumerable problems was able to discontinue his CPAP machine after following this type of diet.

The bottom line is that if you think you or someone else is suffering from sleep apnea, it is very important to go to a sleep lab to be evaluated, and then go to your doctor for a follow-up. Don’t suffer from sleep apnea and, more importantly, don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are effective treatments for this disorder, including diet and/or CPAP.

References: (1) WMJ. 2009;108(5):246. (2) JAMA. 2004;291(16):2013. (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) Am J Respir Crit Care Med. 2012 Nov. 15. (7) APSS annual meeting: abstract No. 0574. (8) BMJ. 2011;342:d3017.

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

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Obesity, sugar, a sedentary lifestyle and abdominal fat contribute to the rise in type 2 diabetes.

By David Dunaief, M.D.

What causes type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 13.3 percent of the U.S. population aged 20 or older has type 2 diabetes, and about 9.3 percent when factoring all ages. For those 65 and older, the prevalence is considerably higher, at 25.9 percent (1).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars, because form is important. Sugar and fruit are not the same with respect to their effects on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage, however, we are talking about the overall prevalence, which is around 9.3 percent in the U.S., as noted in the introduction.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12-ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to municipal efforts to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

The effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a BMI of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels.

It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with articles I’ve written on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

Thus, diabetes is mostly likely a disease caused by a multitude of factors, including obesity, sedentary lifestyle and visceral fat. The good news is that many of these factors are modifiable. Cinnamon and fruit seem to be two factors that help decrease this risk, as does exercise, of course.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make at least some lifestyle modifications. So America, take an active role.

References: (1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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

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Prevention and treatment improve outcome

By David Dunaief, M.D.

Cataracts are incredibly common; about 50 percent of Americans will have a cataract or have had cataract surgery by age 80 (1). Cataracts, the nuclear type, reduce visual acuity in an insidious process. Cataract surgery can resolve this, reducing the risk of falls and hip fracture. At the same time, it can reduce pressure in the eye.

Interestingly, research suggests that a diet rich in carotenoids may prevent the occurrence of cataracts. However, statins may have the reverse effect by increasing risk.

Let’s look at the evidence.

Cataract surgery and hip fracture

In one study, elderly cataract patients who underwent surgery were significantly less likely to experience a hip fracture during a year of follow-up than those who did not have surgery (2). This was a retrospective (backward-looking) observational study, and its size was considerable, with over one million patients ages 65 and older. The results showed a 16 percent reduction in the risk of hip fractures overall. Those who were older, between ages 80 and 84, had the most to gain, with a 28 percent reduction in hip fracture risk.

The increased fall risk and subsequent hip fracture risk among those with cataracts result from decreases in visual acuity and depth perception and a reduction in visual field that accompany cataracts (3). Hip fractures have a tremendous impact on the ability of elderly patients to remain independent. Many of these patients do not regain their prior mobility. Thus, avoiding hip fractures is the best strategy.

Cataract surgery and intraocular pressure

Yet another benefit of cataract surgery is the potential reduction in intraocular pressure (IOP). Why is intraocular pressure (pressure within the eye) important? High IOP has been associated with an increased risk of glaucoma.

A comparative case series (looking at those with and without cataract surgery) utilizing data from the Ocular Hypertension Treatment Study showed that those cataract patients with ocular hypertension (higher than normal pressure in the eye) who underwent cataract surgery saw an immediate reduction in IOP (4). This effect lasted at least three years. The removal of the cataract lowered the IOP by 16.5 percent from 23.9 mm Hg to 19.8 mm Hg. This is close to the low end of glaucoma treatments’ pressure reduction goals, which are 20 to 40 percent. Therefore, cataract surgery may be synergistic with traditional glaucoma treatment.

Cataract surgery and macular degeneration risk

There has been conflicting information in recent years about whether cataract surgery increases the risk of age-related macular degeneration (AMD) progression. A 2009 study suggested that, rather than increasing AMD risk, cataract surgery may uncover underlying AMD pathology that is hidden because the cataract obfuscates the view of the retina (back of the eye) (5). The study’s strengths were the use color retinal photographs and fluorescein angiography (dye in blood vessels of eye), both very thorough approaches.

Cataract prevention with dietary carotenoids

Diet may play a significant role in prevention of cataracts. In the Women’s Health Initiative Observational Study, carotenoids, specifically lutein and zeaxanthin, seem to decrease cataract risk by 23 percent in women with high blood levels of carotenoids, compared to those with low blood levels (6). In fact, those in the highest quintile (the top 20 percent) had an even more dramatic 32 percent risk reduction when compared to those in the bottom quintile (the lowest 20 percent).

As the authors commented, it may not have been just lutein and zeaxanthin. There are more than 600 carotenoids, but these were the ones measured in the study. Some of the foods that are high in carotenoids include carrots, spinach, kale, apricots and mango, according to the USDA. Interestingly, half a cup of one of the first three on a daily basis will far exceed the recommended daily allowance. Thus, it takes a modest consistency in dietary carotenoids to see a reduction in risk.

Vitamin C effect

The impact of vitamin C on cataract risk may depend on the duration of daily consumption. In other words, 10 years seems to be the critical duration needed to see an effect. According to one study, those participants who took 500 mg of vitamin C supplements for 10 or more years saw a 77 percent reduction in risk (7). However, only very few women achieved this goal in the study, demonstrating how difficult it is to maintain supplementation for a 10-year period.

Those who took vitamin C for fewer than 10 years saw no effect in prevention of cataracts. In the well-designed Age-Related Eye Disease Study, a randomized controlled trial, the gold standard of studies, those who received 500 mg of vitamin C supplements along with other supplements did not show any cataract risk reduction, compared to those who did not receive these supplements (1). There were 4,629 patients involved in the cataract study with a duration of 6.3 years of daily supplement consumption. Therefore, I would not rush to take vitamin C as a cataract preventative.

Statin use

Statins have both positive and negative effects, and the effect on the eyes according to one sizable study is negative. In the Waterloo Eye Study with over 6,000 participants, those patients taking statins were at a 57 percent increased risk of cataracts (8). Diabetes patients saw an increased risk of cataracts as well. And in diabetes patients, statins seem to increase the rate at which cataracts occurred.

The authors surmise that this is because higher levels of cholesterol may be needed for the development of epithelial (outer layer) cells and transparency of the lens. This process may be blocked with the use of statins. Before considering discontinuing statins, it is important to weigh the risks with the benefits.

Thus, if you have diminished vision, it may be due to cataracts. It is important to consult an ophthalmologist for diagnosis and, perhaps, cataract surgery, which can reduce your risks of falls, hip fractures and intraocular pressure. For those who do not have cataracts, a diet rich in carotenoids may significantly reduce their risk of occurrence.

References:

(1) nei.nih.gov. (2) JAMA. 2012;308:493-501. (3) J Am Geriatr Soc. 2009 Oct;57(10):1825-1832. (4) Ophthalmology. 2012;119:1826-1831. (5) Arch Ophthalmol. 2009;127:1412-1419. (6) Arch Ophthalmol. 2008;126(3):354-364. (7) Am J Clin Nutr. 1997 Oct;66(4):911-916. (8) Optom Vis Sci 2012;89:1165-1171.

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

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How much water we need to drink depends on diet, activity levels, environment and other factors.

Summer is officially here, accompanied by reports of above-average temperatures from around the country. Dehydration is of particular concern at this time of year. Complications can be mild to severe, ranging from mood changes and headaches to heart palpitations, heat stroke, migraines and heart attacks.

We may be dehydrated prior to experiencing symptoms of thirst. Signals and symptoms of dehydration include tiredness, constipation, dry skin, dizziness or light-headedness, reduced tears and decreased or dark urine (1).

Dehydration can also be caused by medications. Diuretics, which are used by many for high blood pressure, heart failure, swelling and other chronic disorders, are primary culprits, especially in elderly patients.

There are inexpensive blood tests to help confirm mild dehydration. Simple blood urea nitrogen (BUN) and creatinine level tests are part of a basic metabolic panel. If each level on its own is high, this indicates there may be dehydration (2). If the ratio of BUN to creatinine is above 20, this is another signal that a patient may be dehydrated.

In addition, elevated sodium, potassium, urea and glucose are good indicators (3). Another way to confirm dehydration is to look at urine sodium concentrations. If they are low, it’s another red flag (2).

Headaches and migraines

Temperature is a potential trigger for headaches and migraine. As the temperature rises by intervals of 9 degrees, the risk for headache and migraines increases by 8 percent (4). This study involved 7,054 participants from one emergency room site. Warmer temperatures can potentially reduce blood volume in the body, causing dilation of the arteries, resulting in higher risk of headaches and migraines.

In another study, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (5). Headache intensity decreased as well. Anecdotally, I had a patient who experienced a potentially dehydration-induced migraine after playing sports in the sweltering heat of Florida. He had the classic aura and was treated with hydration, Tylenol and caffeine, which helped avoid much of the suffering.

Heart palpitations

Heart palpations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise are contributing factors (6). They occur mainly when we don’t hydrate prior to exercise. All we need to do is drink one glass of water prior to exercise and then drink during exercise to avoid palpitations. Though these are not usually life threatening, they are anxiety producing for patients.

Cardiovascular issues

The Adventist Health Study, an observational study, showed a dose-response curve for men (7). In other words, group one, which drank more than five glasses of water daily, had the least risk of death from heart disease than group two, which drank more than three glasses of water daily. Those in group three, which drank less than two glasses per day, saw the least amount of benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrinogen, a substance that helps clots form.

In a recently published small study, researchers studied the effects of mild dehydration on healthy males in their 20s (8). The study used intermittent, low-intensity walking to induce a 2 percent hydration deficit among study participants. Then, they provided a low water content diet for the remainder of the day.

Participants showed significantly impaired endothelial function. The endothelium is the inner lining of the blood vessels. Endothelial dysfunction can impair the balance between dilation and constriction of the blood vessels. Why is this important? This dysfunction can contribute to cardiovascular events such as heart attacks. While this study involved only 10 participants, it suggests that even mild dehydration can have a dramatic impact on cardiovascular health.

Ways to remain hydrated

How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data but did not find adequate studies to suggest that eight glasses is supported in the literature (10). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like the Mediterranean or DASH diets, have a plant-rich focus. A study mentions that diets with a focus on fruits and vegetables increases water consumption (11). As you may know, 95 percent of their weights is attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Mood and energy levels

In another recent study, mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women (9). In this small study, the mean age of participants was 23; they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

I would also suggest, from my practice experience, hydration prior to exercise.

The myth: Coffee is dehydrating

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (12). With moderate amounts of caffeine, the liquid has a more hydrating effect than the diuretic effect.

Thus, it is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high amount of nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (13). If you overhydrate with water, you can experience similar symptoms to dehydration. It is a good idea to review your medications with your doctor for possible dehydrating side effects.

References:

(1) mayoclinic.org. (2) uptodate.com. (3) BMJ Open online, Oct 21 2015. (4) Neurology. 2009 Mar 10;72(10):922-927. (5) Handb Clin Neurol. 2010;97:161-172. (7) my.clevelandclinic.org. (7) Am J Epidemiol 2002 May 1; 155:827-833. (8) European Journal of Nutrition online, Feb 10 2016. (9) J. Nutr. February 2012 142: 382-388. (10) AJP – Regu Physiol. 2002;283:R993-R1004. (11) Am J Lifestyle Med. 2011;5(4):316-319. (12) Exerc Sport Sci Rev. 2007;35(3):135-140. (13) Br J Ophthalmol. 2005:89:1298–1301

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

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Lifestyle changes may act like combination punches

Muhammad Ali was larger than life until the boxing ring, the stage where he had the loudest megaphone, took its toll.

It is not often that we come across a man who symbolizes so many different facets of life. Muhammad Ali was a fighter, in the literal sense, and his opponents faced an ominous, yet poetic, adversary in the boxing ring. He was also a fighter for racial equality. Ali was larger than life until the boxing ring, the stage where he had the loudest megaphone, took its toll.

Repeated blows to his head, especially to the back of his head, the cerebellar region of the brain responsible for balance and coordination, may have been at least partly responsible for prompting a disease that stole this boxer’s physical prowess and trapped a powerful force in a withering body, leaving him expressionless.

This disease is, of course, Parkinson’s disease. Though it became more and more difficult to move, he remained a fighter in the figurative sense, not allowing a disease to diminish his spirit and bringing hope to others. One of the most moving memories I have of Muhammad Ali is of him lighting the torch to commence the 1996 Summer Olympics in Atlanta, inspiring other athletes.

Parkinson’s disease is a neurodegenerative (the breakdown of brain neurons) disease with the resultant effect of a movement disorder. Most notably, patients with the disease suffer from a collection of symptoms known by the mnemonic TRAP: tremors while resting, rigidity, akinesia/bradykinesia (inability/difficulty to move or slow movements) and postural instability or balance issues. It can also result in a masked face, one that has become expressionless and potentially dementia, depending on the subtype. There are several different subtypes; the diffuse/malignant phenotype has the highest propensity toward cognitive decline (1).

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (2). Why not add back dopamine? Actually, this is the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

What are some of the risk factors? These may include head trauma, reduced vitamin D, milk intake, well water, being overweight, high levels of dietary iron and migraine with aura in middle age.

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

Let’s look at the research.

The role of iron

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

In a small, yet well-designed, randomized controlled trial (RCT), the gold standard of studies, researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (3). This drug was mostly well-tolerated.

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

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

CoQ10

When we typically think of using CoQ10, a coenzyme found in over-the-counter supplements, it is to compensate for depletion from statin drugs or due to heart failure. Doses range from 100 to 300 mg. However, there is evidence that CoQ10 may be beneficial in Parkinson’s at much higher doses. In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to the placebo group (4). Other doses of 300 and 600 mg showed trends toward benefit but were not significant. This was a 16-month trial in a small population of 80 patients. Though the results for other CoQ10 studies have been mixed, these results are encouraging. Plus, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with Parkinson’s disease.

Vitamin D: Good or bad?

In a prospective (forward-looking) study, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (5). This is quite impressive, especially since the highest quartile patients had vitamin D levels that were what we would qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less. There were over 3,000 patients involved in this study with an age range of 50 to 79.

When we think of vitamin D, we wonder whether it is the chicken or the egg. Let me explain. Many times we are deficient in vitamin D and have a disease, but replacing the vitamin does nothing to help the disease. Well, in this case it does. It turns out that vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In an RCT, results showed that 1,200 IU of vitamin D taken daily, may have reduced the progression of Parkinson’s disease significantly on the UPDRS compared to a placebo over a 12-month duration (6). Also, this amount of vitamin D increased the blood levels by two times from 22.5 to 41.7 ng/ml. There were 121 patients involved in this study with a mean age of 72.

Caffeine, anyone?

What role does caffeine play in Parkinson’s? Potentially a beneficial one. In a prospective observational Finnish study involving almost 30,000 participants over 12 years, results showed that one cup of coffee per day reduced the risk of Parkinson’s disease by 60 percent compared to those who consumed none (7). Three cups of caffeinated tea per day also reduced the risk of Parkinson’s by 59 percent. Caffeine may not be right for everyone; however, in this case, it may be beneficial. Though I would not recommend starting to drink caffeine, I would certainly not dissuade patients from drinking it to help prevent Parkinson’s.

So, what have we learned? Though medication with dopamine agonists is the gold standard for the treatment of Parkinson’s disease, lifestyle modifications can have a significant impact on both prevention and treatment of this disease. Similar to combination punches from a great boxer like Muhammad Ali, each lifestyle change in isolation may have modest effects, but cumulatively they might pack quite a wallop. The most exciting part is that lifestyle modifications have the potential to slow the progression the disease and thus have a protective effect. Iron chelators specific to the brain may also be very important in disease modification. This also brings vitamin D back into the fold as a potential disease modifier.

References:

(1) JAMA Neurol. 2015;72:863-873. (2) uptodate.com. (3) Antioxid Redox Signal. 2014;10;21(2):195-210. (4) Arch Neurol. 2002;59(10):1541-1550. (5) Arch Neurol. 2010;67(7):808-811. (6) Am J Clin Nutr. 2013;97(5):1004-1013. (7) Mov Disord. 2007;22(15):2242-2248.

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