Gallstones are a very common gastrointestinal disease; they affect up to 20 million Americans between the ages of 20 and 74, with a more than two-times increased occurrence in women than in men, according to the NHANES III survey (1). There are two types of gallstones, 80 percent of which are cholesterol stones and 20 percent of which are pigment stones.

Common symptoms
Gallstones may be asymptomatic; however, when gallstones block either the cystic or common bile ducts, symptoms occur. Symptoms include dull or crampy abdominal pain that is exacerbated by meals and lasts one to five hours. Jaundice, which includes yellowing of skin and eyes, is another symptom. Others include nausea and vomiting, rapid heart rate, hypotension (low blood pressure) and fever (2).

Tests used for diagnosis
Blood tests include complete blood count, where there may be a rise in white blood cells; liver enzymes; and the pancreatic enzymes lipase and amylase. In general, diagnostic tests that have more accuracy are the endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). However, these are invasive tests. Less accurate but noninvasive tests include abdominal x-ray, ultrasound and CAT Scan (CT). The tests used also depend on where the stone may be located. Hepatobiliary (HIDA) scans are accurate if the stone is located in the cystic duct. And magnetic resonance retrograde cholangiopancreatography (MRCP) is used if the stone is thought to be located in the common bile duct (2).

What are the risk factors?
There are a multitude of risk factors. Some of these are modifiable, some others are not. The modifiable ones include obesity, measured by body mass index (BMI); rapid weight loss; fat consumption; hormone replacement therapy (HRT); oral contraceptives; decreased physical activity; Crohn’s disease and certain drugs. One non-modifiable risk factor is age; the older we get, the higher the risk, with 40 years of age being the demarcation line (3). Other risk factors are gender, with females being more predisposed ; pregnancy; and family history (4).

Let’s look at the evidence.

Obesity
Obesity may play an important role. Obesity is not age-discriminant; it can impact both adults and children. The reason obesity is implicated is potentially due to bile becoming supersaturated (5). Bile is a substance produced in the liver and stored in the gallbladder. Bile aids in the digestion or breakdown of fats in the small intestines. Crystals may form, creating cholesterol gallstones from the bile.

Body Mass Index
A body mass index of greater than 30 kg/m2 is considered obese. In a meta-analysis of two prospective, forward-looking observational trials, Copenhagen General Population Study and the Copenhagen City Heart Study, those in the highest quintile of BMI were almost three times as likely to experience symptomatic gallstones compared to those who were in the lowest quintile (6). The highest quintile was those who had a mean BMI of 32.5 kg/m2 and thus were obese, whereas those in the lowest quintile had a mean BMI of 20.9 kg/m2. This is a comparison of ideal to obese BMI. Not surprisingly, since women in general have a higher risk of gallstones, they also have a higher risk when their BMI is in the obese range compared to men, a 3.36-fold increase and 1.51-fold increase, respectively.

Also, the research showed that for every 1 kg/m2 increase in BMI, there was a 7 percent increase in the risk of gallstones. Those who had genetic variants that increased their likelihood of an elevated BMI had an even greater increase in gallstone risk —17 percent — per 1 kg/m2. In the study population of approximately 77,000, more than 4,000 participants became symptomatic for gallstones.

Gallstones in children
Sadly, obese children are not immune to gallstones, even though they are young. In a prospective observational study based on Kaiser Permanente data from southern California, children who were overweight had a twofold increased risk of gallstones (7). But if that is not enough, girls who were extremely obese had a higher propensity for gallstones, similar to women in the previous study, with a greater than sevenfold increase compared to a still very substantial greater-than-threefold increase for obese boys. Hispanic children were affected the most. The age range in this study was between 10 and 19 years old. Obesity is a disease that is blind to age.

Physical activity
We know physical activity is very important to stave off many diseases, but in this case, the lack of physical activity can be detrimental. In the Physicians’ Health Study, a prospective observational trial, those in the lowest quintile of activity between the ages of 40 and 64 had a 72 percent increased risk of gallstone formation, and those 65 and older had a 33 percent increased risk. (8). Also, men who were 65 and older and watched television more than six hours a week were at least three times as likely to have gallstones as those who watched fewer hours. There was a substantial increased risk for those under 65, as well, though to a slightly lesser degree.

Diabetes rears its ugly head
Just like with obesity, diabetes is almost always a culprit for complications. In a prospective observational study, those with diabetes were at a significant 2.55-times greater risk of developing gallstones than those without (9). Again, women had a higher propensity than men, but both had significant increases in the risk of gallstone formation, 3.85-times and 2.03-times, respectively. There were almost 700 participants in this study. The researchers believe that an alteration in glucose (sugar) metabolism may create this disease risk.

Hormone replacement therapy
If you needed another reason to be leery of hormone replacement therapy (HRT), then gallstones might be it. In a prospective observational trial, women who used HRT compared to those who did not, had a 10 percent increased risk in cholecystectomy — removal of the gallbladder — to treat gallstones (10). Though this may not sound like a large increase, oral HRT increased the risk 16 percent, and oral estrogen-only therapy without progestogens increased the risk the most, 38 percent. Transdermal HRT did not have a significantly increased risk.

It is never too early or too late to treat obesity before it causes, in this case, gallstones. With a lack of exercise, obesity is exacerbated and, not surprisingly, so is symptomatic gallstone formation. Diabetes needs to be controlled to prevent complications. HRT, unless menopausal symptoms are unbearable, continues to show why it may not be a good choice. Next week, we will look at the complications of gallstones and how to prevent them.

References:
Gastroenterology. 1999;117:632. (2) emedicine.medscape.com. (3) J Hepatol. 1993;18 Suppl 1:S43. (4) uptodate.com. (5) Best Pract Res Clin Gastroenterol. 2014 Aug;28:623-635. (6) Hepatology. 2013 Dec;58:2133-41. (7) J Pediatr Gastroenterol Nutr. 2012;55:328-333. (8) Ann Intern Med. 1998;128:417. (9) Hepatology. 1997;2:787. (10) CMAJ. 2013;16;185:549-50.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

Parkinson’s disease is a neurodegenerative disease, which means there is progressive breakdown of neurons. Traditional medications that focus on dopamine levels and receptors help improve symptoms, sometimes dramatically, yet they have limitations. Medications can’t prevent the breakdown of the neurons themselves. Also, drug benefits may eventually “wear off.”

Parkinson’s typically affects people who are older than 60. There are over one million people in North America directly affected by this disease, but countless family member caregivers are indirectly affected as well (1).

This article’s focus is to provide an overview of Parkinson’s, including risk factors, diagnosis and alternative treatments that may enhance traditional treatments.

Significance of eye tremors

The common triad of symptoms for diagnosing Parkinson’s includes rigidity, tremor and bradykinesia (slow gait). Parkinson’s tremors typically occur in the limbs; they are usually resting tremors, which means they are suppressed by movement. But this may not be the whole story. We may also want to look at the eyes. It appears that Parkinson’s disease patients have ocular fixation instability, meaning that, for example, when they focus on a point on a computer screen, their eyes oscillate and may have trouble focusing. This happens to a greater degree in the vertical direction than the horizontal (2).

In a case-control trial, which compared Parkinson’s patients with healthy participants, 63 percent of the Parkinson’s patients, in addition to eye tremors, experienced difficulty with vision at some point during the testing. The area of the eye that affected was the fovea — part of the retina (back of the eye) responsible for sharp central vision. The authors believe that eye testing may provide an accurate way to diagnose the disease.

Pesticides may have negative effects

It appears in meta-analysis (a group of 46 trials) that pesticides increase the risk of Parkinson’s disease (3). Insecticides and herbicides appeared to have more impact, whereas fungicides were not associated with increased risk.

The studies were not completely consistent, even though there was a 62 percent overall increased risk. However, it would be premature to declare that pesticides have a cause-and-effect relationship with Parkinson’s disease. There were no randomized clinical trials, and there were several different types of trials analyzed. Many past studies have had mixed results. Also, it was unclear what type of pesticide exposure occurred and at what level. The authors did not definitively say that it was from consumption of foods, but the results are interesting and may give a boost to the validity of organic foods.

Dairy’s potential detrimental impact

The National Dairy Council wants you to believe that dairy makes you big and strong. However, in the prospective (forward-looking) Cancer Prevention Study II, men who consumed the most dairy were found to have as much as an 80 percent increased Parkinson’s disease risk compared to those who consumed the least (4).The risk is higher than the pesticide study mentioned above. There was also an increased risk with women, but not as dramatic. When results combined both sexes, there was an overall 60 percent increased risk. Therefore, if there is a family history of Parkinson’s, it might be wise to consider keeping dairy to a minimum.

Dietary effect

In a meta-analysis that looked at the Nurses’ Health Study and the Health Professionals Follow-up Study, results showed diets that focused on fruits, vegetables, whole grains, nuts and seeds and fish and poultry demonstrated a 30 percent reduction in Parkinson’s disease risk (5). This effect may be due to flavonoids, bioactive compounds in plant-rich diets. It is surmised that these compounds may have neuroprotective effects. Why is this important? The neuroprotective effect may help prevent neuron (nerve cell) breakdown because of their antioxidant and anti-inflammatory properties (6). However, the neuroprotective effect has never been definitively demonstrated in human trials, but only in animal studies.

Exercise! Exercise! Exercise!

Exercise may be used in concert with therapeutics in treating Parkinson’s disease, and the potential goes beyond medications in helping with motor function and stability. Two that have shown good results are resistance training and tai chi.

Resistance training — specifically weight training — may have significant benefits, according to a two-year randomized controlled trial, the gold standard of trials (7). The patients involved in the study had Parkinson’s for a mean of seven years and were not on medication. Patients were assigned to one of two groups; they either exercised with weights or participated in a regimen of balance, flexibility and strengthening exercises. Both groups exercised twice a week for one hour per day over a 24-month period.

The resistance training group saw a significant improvement in motor function as they gradually increased the level of resistance. Though this study was small, including 38 patients, these results are encouraging.

Tai chi is no slouch

Postural stability is important to the functionality of a Parkinson’s disease patient. In a National Institutes of Health-funded randomized clinical trial, tai chi significantly improved postural stability when comparing it to both resistance training and stretching (8). Tai chi was instrumental also in reducing falls — even three months after patients stopped tai chi. The mild to moderate Parkinson’s patients in the study performed tai chi for one hour twice a week.

It is exciting that there may be a more definitive way to diagnose Parkinson’s disease by testing the eyes for tremors, rather than the traditional compilation of symptoms. Even though it is not clear where pesticide exposure occurred, it may be prudent for people with a high risk of Parkinson’s to lean toward an organic, plant-rich diet for prevention.

In addition, if a Parkinson’s disease patient exercised four times a week, alternating between tai chi and resistance training, they would get the best of both worlds: potential improvement in postural stability and in motor skills. Note that exercises might need to be modified to accommodate current physical constraints; for example, arm exercises can be performed seated for patients with balance issues. Always consult your physician before beginning an exercise routine.

References:

(1) N Engl J Med 1998;339(15):1044. (2) Arch Neurol. 2012;69(8):1011-1017. (3) Environ Health Perspect. 2012;120(3):340-347. (4) Am J Epidemiol. 2007 May 1;165(9):998-1006. (5) Am J Clin Nutr. 2007 Nov;86(5):1486-1494. (6) Eur J Pharmacol. 2006;545(1):51-64. (7) Mov Disord. 2013 Aug;28(9):1230-1240. (8) N Engl J Med 2012;366:511-519.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

How do we protect one of our most valued assets, our infrastructure? Not roads and bridges, but our bones. When we think of bone fractures as a child or young adult, we think of short-term pain and inconvenience, but usually we recover without long-term consequences.

However, as we get older — especially for the elderly — fractures can be a lot more significant, with potentially life-altering or life-ending consequences. Osteoporosis is a silent disease that affects millions of patients, most commonly, but by no means exclusively, postmenopausal women. The trend is for low bone mass and osteoporosis diagnoses to increase by 29 percent from 2010 to 2030. Osteoporosis is where there is bone loss, weakening of the bones, and small deleterious changes in the architecture of the bone over time that may result in fractures with serious consequences (1).

One way to measure osteoporosis is with a dual-energy x-ray absorptiometry scan for bone mineral density. Osteopenia is a slightly milder form that may be a precursor to osteoporosis. However, we should not rely on the DXA scan alone; risk factors are important, such as a family or personal history of fractures as we age. The Fracture Risk Assessment Tool (FRAX) is more thorough for determining the 10-year fracture risk. Those who have a risk of fracture that is three percent or more should consider treatment with medications. A link to the FRAX tool can be found at www.shef.ac.uk/FRAX.

Most of us have been told since we were young that we need more calcium to make sure we have strong bones. In fact, the National Osteoporosis Foundation recommends that we get 1000-1200 mg per day of calcium if we are >50 years old (2). Recommendations vary by sex and age. This would be mostly from diet, but also from supplements. However, the latest research suggests that calcium for osteoporosis prevention may not be as helpful as we thought.

The under/overmedication treatment paradox

Depending on the population, we could be over-treating or under-treating osteoporosis. In the elderly population that has been diagnosed with osteoporosis, there is under-treatment. One recent study showed that only 28 percent of patients who are candidates for osteoporosis drugs are taking the medication within the first year of diagnosis (3). The reason most were reluctant was that they had experienced a recent gastrointestinal event and did not want to induce another with osteoporosis medications, such as bisphosphonates. The data were taken from Medicare records of patients who were at least 66 years old.

On the other hand, as many as 66 percent of the women receiving osteoporosis medications may not have needed it, according to a retrospective study (4). This is the overtreatment population, with half these patients younger, between the ages of 40 and 64, and without any risk factors to indicate the need for a DXA scan. This younger population included many who had osteopenia, not osteoporosis.

Also, the DXA scan may have shown osteoporosis at what the researchers described as nonmain sites in one-third of patients diagnosed with the disease. Main sites, according to the International Society for Clinical Densitometry recommendations, would be the anterior-posterior spine, hip, and femoral neck. A nonmain site in this review was the lateral lumbar spine. Before you get a DXA scan, make sure you have sufficient risk factors, such as family or personal history of fracture, age, and smoking history. When the DXA scan is done, make sure it is interpreted at the main sites. If you are not sure, have another physician consult on the results.

We all need calcium to
prevent osteoporosis, right?

Calcium has always been the forefront of prevention and treatment of osteoporosis. However, two studies would have us question this approach. Results of one meta-analysis of a group of 59 randomized controlled trials showed that dietary calcium and calcium supplements with or without vitamin D did increase the bone density significantly in most places in the body, including the femoral neck, spine and hip (5). Yet the changes were so small that they would not have much clinical benefit in terms of fracture prevention.

Another meta-analysis of a group of 44 observational dietary trials and 26 randomized controlled trials did not show a benefit with dietary or supplemental calcium with or without vitamin D (6). There was a slight reduction in nonsignificant vertebral fractures, but not in other places, such as the hip and forearm. Dietary calcium and supplements disappointed in these two trials.

Does this mean calcium is not useful? Not so fast!

In some individual studies that were part of the meta-analyses, the researchers mentioned that dairy, specifically milk, was the dietary source on record, and we know milk is not necessarily good for bones. But in many of the studies, the researcher did not differentiate between the sources of dietary calcium. This is a very important nuance. Calcium from animal products may increase inflammation and the acidity of the body and may actually leach calcium from the bone, while calcium from vegetable-rich, nutrient-dense sources may be better absorbed, providing more of an alkaline and anti-inflammatory approach. This would be a good follow-up study, comparing the effects of calcium from animal and plant-based dietary sources.

What can be done to improve the situation?

Yoga used to be on the fringe of society. Now, it has become more prevalent and part of mainstream exercise. This is a good trend, since this type of exercise may have a big impact on prevention and treatment of osteoporosis. In a small pilot study, the results showed that those who practiced yoga had an increase in their spine and hip bone density compared to those who did not (7). There were 18 participants in this trial.

The researchers were encouraged by these results, so they increased the number of participants in another study. The results showed that 12 minutes of yoga daily or every other day significantly increased the bone density from the start of the study in both the spine and femur, the thigh bone (8). There was also an increase in hip bone density, but this was not significant. The strength of the study includes its 10-year duration. However, one weakness was that this trial did not include a control group. Another was that 741 participants started the trial, but only 227 finished, less than one-third. Of those, 202 were women. Significantly, prior to the study there were 109 fractures in the participants, most of whom had osteoporosis or osteopenia, but none had yoga-related fractures by the end of the trial. The “side effects” of yoga include improved mobility, posture, strength and a reduction in anxiety. The researchers gave a nice road map of specific beneficial poses. Before starting a program, consult your doctor.

The moral of the story is that exercise is beneficial. Yoga may be another simple addition to this exercise regimen. Calcium may be good or bad, depending on its dietary source. Be cautious with supplemental calcium; it does have side effects, including kidney stones, cardiovascular events, and gastrointestinal symptoms, and consult with your doctor to assess whether you might be in an overtreatment or under-treatment group when it comes to medication.

References: (1) uptodate.com. (2) Osteoporos Int 2014;25:2359–2381. (3) Clin Interv Aging. 2015;10:1813-24. (4) JAMA Intern Med. online Jan. 4, 2016. (5) BMJ 2015; 351:h4183. (6) BMJ 2015; 351:h4580. (7) Top Geriatr Rehabil.2009; 25(3); 244-250. (8) Top Geriatr Rehabil. online Nov. 5, 2015.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

Obesity is a disease that nobody wants and everyone tries to avoid, yet it affects more people than almost any other disease. It is complicated, for there are a multitude of contributors. Lifestyle modifications are of the utmost importance when it comes to a solution. These include diet, fitness and stress reduction.

There is a foundation of components to almost every diet. At the base of every good food pyramid should be a vegetable‐rich, nutrient‐dense diet. In other words, people should aim to consume these elements because they have been shown to help with weight loss, treat chronic disease and improve overall health (1). Diets such as the DASH (Dietary Approaches to Stop Hypertension) diet and the Mediterranean‐type diet have shown beneficial effects for not only weight loss but also other diseases such as hypertension, chronic kidney disease, diabetes and heart disease.

A New York Times article published on Jan. 3, 2016, entitled “A Healthy Diet’s Main Ingredients? Best Guesses,” notes that we don’t know all the science behind what makes a good diet. I would agree with this, since research is an evolving process.

However, one element in the article that I strongly disagree with is that the principal investigator for a 2006 study on whether a low‐fat diet reverses disease concluded that diet composition has no effect in reversing chronic disease (2). Of course, she was making this statement in 2006, when there was less evidence of potential reversal of disease with diet. Low‐fat diets in isolation are hard to perform; most of the participants can’t stick to the regimen and/or they replace fat with refined grains.

Also, while this may have been the case for this one specific low‐fat diet study, we have seen time and again that a vegetable‐rich, nutrient‐dense diet does have effects that may reverse diseases such as cardiovascular disease, diabetes, chronic kidney disease and a host of others. Caldwell Esselstyn, M.D., showed the effect of a vegetable‐rich, nutrient‐dense diet on cardiovascular disease in 1995 (3). Dean Ornish, M.D., showed the effect of a similar diet on prostate cancer reversal in 2008 (4). I see reversal of chronic diseases, such as those mentioned above, regularly in my practice. Diet composition, therefore, does matter when it comes to reversing disease.

I would agree, as the New York Times article alludes, that we can’t reduce one macronutrient in isolation and expect great results. For example, the dietary guidelines have been obsessed for many years with low fat. Unfortunately, this has not resulted in better health and less obesity as mentioned above. The most recent statistics show an increase in the prevalence of obesity for adults in the United States. In fact, the obesity rate has increased by 17 percent over the last 10 years as recently documented by the CDC (5). Now 38 percent of Americans are obese [body mass index (BMI) >30 kg/m2), more are overweight (BMI 25‐29.9 kg/m2) or normal weight (BMI 18.5‐24.9 kg/m2). The greatest prevalence is among those who are middle aged, 40‐59 years, followed by those 60 years and older. The good news is that the obesity rate has not increased for children. However, for adults, this epidemic continues to grow. And the expense to the U.S. health care system is enormous, with $147 billion spent in 2008 (6).

Why is obesity good? The answer is not necessarily what you think! Obesity is beneficial because it is the body’s cry for help. The solution is multifactorial, including diet, exercise and stress management.

Can you be obese and fit?

Exercise always seems to be beneficial. While it may not garner tremendous weight loss, it is helpful in maintaining weight loss, and it may reduce the risk of premature death. A recent observational study in Sweden found that those in the highest quintile of aerobic exercise reduced their risk of premature death by 51 percent (7). Those who were normal weight, regardless of fitness, had a greater reduction in premature death — 30‐48 percent — than even those who were in the highest aerobic activity level, but obese.

However, within the obese cohort, those who were in the highest quintile of fitness did see a 29 percent reduction in premature death. The moral of the story is that those who are obese are not fit compared to those who are normal weight, regardless of activity level.

Yet, among obese patients, there is a gradation with premature death: Those who are most aerobically active benefit over their obese counterparts who are not. This Swedish study began with a population of 18‐year‐old men and followed them for almost 30 years.

What is a TOFI and why is it dangerous?

A TOFI is an acronym meaning thin on the outside, fat on the inside. For example, patients who have central obesity can have normal BMIs. How do you measure central obesity? It involves the waist‐to‐hip ratio (WHR). When the WHR is over a certain level, then there is central obesity. For men it is >0.90 WHR and for women it is a >0.85 WHR. A recent observational study showed that patients who had central obesity but normal BMIs had a greatly increased risk for mortality (8).

In men, there was an 87 percent increased risk of death. But even more interesting was the fact that normal weight, centrally obese men had two times the risk of mortality compared to those who were obese without central obesity. For women there was a 48 percent increased risk compared to those with normal weight without central obesity. Patients were followed for 14 years. Therefore, just because someone has normal BMI does not mean they are healthy or fit. The researchers recommended weight training to help with central obesity beyond just diet.

Stress and weight gain, really?

Yes, really! Psychosocial or emotional stress may be significant with weight. In a meta‐analysis (a group of 14 observational studies), results showed the effects of psychosocial stress were related to weight gain (9). The researchers hypothesized that it may have to do with the hypothalamus‐pituitary‐adrenal (HPA) axis, which raises the level of cortisol release in the blood. The weight gain occurs most commonly around the waist.

There is a blood test that measures morning cortisol levels, which is when cortisol is highest. If cortisol is above normal, then supplements such as l‐theanine, valerian root or fish oil, as well as dietary changes, exercise, meditation, yoga and some medications can help. We also tend to eat when given stressful tasks to perform, especially when presented with food (10).

To reiterate, a positive way to think about obesity is that the body is screaming for change. Also, central obesity can occur in normal weight individuals and go undetected. Its impacts are as great as, if not greater than, high BMI. But, fortunately, most contributors to obesity are modifiable.

References:

(1) Altern Ther Health Med. 2008 May‐Jun;14(3):48‐53. (2) JAMA. 2006 Jan 4;295(1):39‐49. (3) J Fam Pract. 1995 Dec;41(6):560‐568. (4) Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369‐8374. (5) cdc.gov/nchs/data/databriefs/db219.htm. (6) Health Aff (Millwood). 2009 Sep‐Oct;28(5):w822‐831. (7) Int J Epidemiol. online Dec 20, 2015. (8) Ann Intern Med. online Nov. 9, 2015. (9) Obesity (Silver Spring). 2011;19(4):771‐778. (10) Stress. 2015;18:507‐551.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

Vitamin D is one the most widely publicized and important supplements. We get vitamin D from the sun, food and supplements. With our days at their shortest of the year here, in the Northeast, I thought it would be worthwhile to explore what we know about Vitamin D supplementation.

Vitamin D has been thought of as an elixir for life, but is it really? There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that vitamin D may be effective in a wide swath of chronic diseases, both in prevention and as part of the treatment paradigm. However, many questions remain. As more data come along, their meaning for vitamin D becomes murkier. For instance, is the sun the best source of Vitamin D?

At the 70th annual American Academy of Dermatology meeting, Dr. Richard Gallo who was involved with the Institute of Medicine recommendations, spoke about how, in most geographies, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water fatty fish, such as salmon, sardines and tuna.

We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular and autoimmune diseases and cancer.

There is no consensus on the ideal blood level for vitamin D. The Institute of Medicine recommends more than 20 ng/dl, and The Endocrine Society recommends at least 30 ng/dl. More experts and data lean toward the latter number.

Skin cancer

Vitamin D did not decrease non-melanoma skin cancers, known as NMSCs, such as squamous cell and basal cell carcinoma. It may actually increase them, according to one study done at a single center by an HMO (1). The results may be confounded, or blurred, by UV radiation from the sun, so vitamin D is not necessarily the culprit. Most of the surfaces where skin cancer was found were sun exposed, but not all of them.

The good news is that, for postmenopausal women who have already had an NMSC bout, vitamin D plus calcium appears to reduce its recurrence, according to the Women’s Health Initiative study (2). In this high-risk population, the combination of supplements reduced risk by 57 percent. Unlike the previous study, vitamin D did not increase the incidence of NMSC in the general population. NMSC occurs more frequently than breast, prostate, lung and colorectal cancers combined (3).

Cardiovascular mixed results

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (4).

However, a small randomized controlled trial, the gold standard of studies, calls the cardioprotective effects of vitamin D into question (5). This study of postmenopausal women, using biomarkers, such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study endpoints. However, these results do make you think.

Weight benefit

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (6).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.

Mortality decreased

In a recent meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (7). The difference between the groups was statistically important, but clinically small: 9 percent reduction with vitamin D plus calcium and 7 percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

USPSTF recommendations

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women the combination of vitamin D 400 IUs plus calcium 1000 mg to prevent fractures (8). It does not seem to reduce fractures and increases the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

Need for clinical trials

We need clinical trials to determine the effectiveness of vitamin D in many chronic diseases, since it may have beneficial effects in preventing or helping to treat them (9). Right now, there is a lack of large randomized clinical trials. Most are observational, which gives associations, but not links. The VITAL study is a large RCT looking at the effects of vitamin D and omega-3s on cardiovascular disease and cancer. It is a five-year trial, and the results should be available in 2016.

When to supplement?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it may play an integral role with many disorders.

References:

(1) Arch Dermatol. 2011;147(12):1379-84. (2) J Clin Oncol. 2011 Aug 1;29(22):3078-84. (3) CA Cancer J Clin. 2009;59(4):225-49. (4) Circulation. 2008 Jan 29;117(4):503-11. (5) PLoS One. 2012;7(5):e36617. (6) J Women’s Health (Larchmt). 2012 Jun 25. (7) J Clin Endocrinol Metabol. online May 17, 2012. (8) AHRQ Publication No. 12-05163-EF-2. (9) Endocr Rev. 2012 Jun;33(3):456-92.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

For most of us, exercise is not a priority during the winter months, especially during the holiday season. We think that it is okay to let ourselves go and that a few more pounds will help insulate us from the anticipated cold weather, when we will lock ourselves indoors and hibernate. Of course I am exaggerating, but I am trying to make a point. During the winter, it is even more important to put exercise at the forefront of our consciousness, because we tend to gain the most weight during the Thanksgiving to New Year holiday season (1).

Many times we are told by the medical community to exercise, which of course is sage advice. It seems simple enough; however, the type, intensity level and frequency of exercise may not be defined. For instance, any type of walking is beneficial, right? Well, as one study that quantifies walking pace notes, some types of walking are better than others, although physical activity is always a good thing compared to being sedentary.

We know exercise is beneficial for prevention and treatment of chronic disease. But another very important aspect of exercise is the impact it has on specific diseases, such as diabetes and osteoarthritis. Also, certain supplements and drugs may decrease the beneficial effects of exercise. They are not necessarily the ones you think. They include resveratrol and nonsteroidal anti-inflammatory drugs (such as ibuprofen). Let’s look at the evidence.

Walking with a spring in your step

While pedometers give a sense of how many steps you take on a daily basis, more than just this number is important. Intensity, rather than quantity or distance, may be the primary indicator of the benefit derived from walking.

In the National Walkers’ Health Study, results showed that those who walk with more pace are more likely to decrease their mortality from all causes and to increase their longevity (2). This is one of the first studies to quantify specific speed and its impact. In the study, there were four groups. The fastest group was almost jogging, walking at a mean pace of less than 13.5 minutes per mile, while the slowest group was walking at a pace of 17 minutes or more per mile.

The slowest walkers had a higher probability of dying, especially from dementia and heart disease. Those in the slowest group stratified even further: those whose pace equaled 24-minute miles or greater had twice the risk of death, compared to those who walked with greater speed.

However, the most intriguing aspect of the study was that there were big differences in mortality reduction in the second slowest category compared to the slowest, which might only be separated by a minute-per-mile pace. So don’t fret: you don’t have to be a speedwalker in order to get significant benefit.

Mind-body connection

The mind also plays a significant role in exercise. When we exercise, we tend to beat ourselves up mentally because we are disappointed with our results. The results of a new study say that this is not the best approach (3). Researchers created two groups. The first was told to find four positive phrases, chosen by the participants, to motivate them while on a stationary bike and repeat these phrases consistently for the next two weeks while exercising.

Members of the group who repeated these motivating phrases consistently, throughout each workout, were able to increase their stamina for intensive exercise after only two weeks, while the same could not be said for the control group, which did not use reinforcing phrases.

‘Longevity’ supplement may have negative impact

Resveratrol is a substance that is thought to provide increased longevity through proteins called sirtuin 1. So how could it negate some benefit from exercise? Well it turns out that we need acute inflammation to achieve some exercise benefits, and resveratrol has anti-inflammatory effects. Acute inflammation is short-term inflammation and is different from chronic inflammation, which is the basis for many diseases. In a small randomized controlled study, treatment group participants were given 250 mg supplements of resveratrol and saw significantly less benefit from aerobic exercise over an eight-week period, compared to those who were in the control group (4). Participants in the control group had improvements in both cholesterol and blood pressure that were not seen in the treatment group. This was a small study of short duration, although it was well designed.

Impact on diabetes complications

Unfortunately, Type 2 diabetes is on the rise, and the majority of these patients suffer from cardiovascular disease. Drugs used to control sugar levels don’t seem to impact the risk for developing cardiovascular disease. So what can be done? In a recent prospective (forward-looking) observational study, results show that diabetes patients who exercise less frequently, once or twice a week for 30 minutes, are at a higher risk of developing cardiovascular disease and almost a 70% greater risk of dying from it than those who exercised at least three times a week for 30 minutes each session. In addition, those who exercised only twice a week had an almost 50% increased risk of all-cause mortality (5).

The study followed more than 15,000 men and women with a mean age of 60 for five years. The authors stressed the importance of exercise and its role in reducing diabetes complications.

Fitness age

You can now calculate your fitness age without the use of a treadmill, according to the HUNT study [6]. A new online calculator utilizes basic parameters such as age, gender, height, weight, waist circumference and frequency and intensity of exercise, allowing you to judge where you stand with exercise health. This calculator can be found at www.ntnu.edu/cerg/vo2max. The results may surprise you.

Even in winter, you can walk and talk yourself to improved health by increasing your intensity while repeating positive phrases that help you overcome premature exhaustion. Frequency is important as well. Exercise can also have a significant impact on complications of chronic diseases, such as cardiovascular disease and resulting death with diabetes. When the weather does become colder, take caution when walking outside to avoid black ice or use a treadmill to walk with alacrity. Getting outside during the day may also help you avoid the winter blues.

References:

(1) N Engl J Med. 2000;342:861-867. (2) PLoS One. 2013;8:e81098. (3) Med Sci Sports Exerc. 2013 Oct. 10. (4) J Physiol Online. 2013 July 22. (5) Eur J Prev Cardiol Online. 2013 Nov. 13. (6) Med Sci Sports Exerc. 2011;43:2024-2030.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

Diabetes just won’t go away. It seems that every time I write about the disease, the news is doom and gloom about how it has become a pandemic. The prevalence, or the number with the disease, and the incidence, or the growth rate of the disease, always seem to be on the rise, with little end in sight.

Depression and stress

We don’t want to make you depressed or stressed, especially since these conditions combined with diabetes can have dangerous outcomes. In fact, in a recent observational study, results showed that diabetes patients with stress and/or depression had greater risk of cardiovascular events and death, compared to those with diabetes alone. When diabetes patients had stress or depression, there was a 53 percent increased risk of death from cardiovascular disease (1). And in those diabetes patients who had both stress and depression, there was a two-times greater risk of death from heart disease than in those without these mental health issues. These results need to be confirmed with more rigorous study.

Something to brighten your day!

However, there is good news. According to the Centers for Disease Control and Prevention, the incidence, or the rate of increase in new cases, has begun to slow for the first time in 25 years (2). There was a 20 percent reduction in the rate of new cases in the six-year period ending in 2014. This should help to brighten your day. However, your optimism should be cautious; it does not mean the disease has stopped growing, it means it has potentially turned a corner in terms of the growth rate, or at least we hope. This may relate in part to the fact that we have reduced our consumption of sugary drinks such as soda and orange juice.

By the way, the answers to the quiz questions are 1) d and 2. True, but not all patients have a weight issue.

Get up, stand up!

It may be easier than you think to reduce the risk of developing diabetes. This goes along with the answer to the first question: standing and walking may be equivalent in certain circumstances for diabetes prevention. In a recent, small, randomized control trial, the gold standard of studies, results showed that when sitting, those who either stood or walked for a five-minute duration every 30 minutes, had a substantial reduction in the risk of diabetes, compared to those who sat for long uninterrupted periods (3).

There was a postprandial, or post-meal, reduction in the rise of glucose of 34 percent in those who stood and 28 percent reduction in those who walked, both compared to those who sat for long periods continuously in the first day. The effects remained significant on the second day. A controlled diet was given to the patients. In this study, the difference in results for the standers and walkers was not statistically significant.

The participants were overweight, postmenopausal women who had prediabetes, HbA1C between 5.7 and 6.4 percent. The HbA1C gives an average glucose or sugar reading over three months. The researchers hypothesize that this effect of standing or walking may have to do with favorably changing the muscle physiology. So, in other words, a large effect can come from a very small but conscientious effort. This is a preliminary study, but the results are impressive.

Can prediabetes and diabetes have similar complications?

Diabetes is much more significant than prediabetes, or is it? It turns out that both stages of the disease can have substantial complications. In a recent study of those presenting in the emergency room with acute coronary syndrome, those who have either prediabetes or diabetes have a much poorer outcome. ACS is defined as a sudden reduction in blood flow to the heart, resulting in potentially severe events, such as heart attack or unstable angina (chest pain).

In the patients with diabetes or prediabetes, there was an increased risk of death with ACS as compared to those with normal sugars. The diabetes patients experienced an increased risk of greater than 100 percent, while those who had prediabetes had an almost 50 percent increased risk of mortality over and above the general population with ACS. Thus, both diabetes and prediabetes need to be taken seriously. Sadly, most diabetes drugs do not reduce the risk of cardiac events. And bariatric surgery, which may reduce or put diabetes in remission for five years, did not have an impact on increasing survival (4).

What do the prevention guidelines tell us?

The United States Preventive Services Task Force renders recommendations on screening for diseases. On one hand, I commend them for changing their recommendation for diabetes screening. In 2008, the USPSTF did not believe the research provided enough results to screen asymptomatic patients for abnormal sugar levels and diabetes. However, in October 2015, the committee drafted guidelines suggesting that everyone more than 45 years old should be screened, but the final guidelines settled on screening a target population of those between the ages of 40 and 70 who are overweight or obese (5). They recommend that those with abnormal glucose levels have intensive lifestyle modification as a first step.

This is a great step forward, as most diabetes patients are overweight or obese; however, 15-to-20 percent of diabetes patients are within the normal range for body mass index (6). So this screening still misses a significant number of people. I don’t know why they didn’t stick with the original recommended population, although, this too might still miss the younger population, which is also at risk.

Potassium: it’s not just for breakfast anymore

When we think of potassium, the first things that comes to mind are bananas, which do contain a significant amount of potassium, as do other plant-based foods. Those with rich amounts of potassium include dark green, leafy vegetables; almonds; avocado; beans and raisins. We know potassium is critical for blood pressure control, but why is this important to diabetes?

In a recent observational study, results showed that the greater the exertion of potassium through the kidneys, the lower the risk of cardiovascular disease and kidney dysfunction in those with diabetes (7). There were 623 Japanese participants with normal kidney function at the start of the trial. The duration was substantial, with a mean of 11 years of follow-up. Those who had the highest quartile of urinary potassium excretion were 67 percent less likely to experience a cardiovascular event or kidney event than those in the lowest quartile. The researchers suggested that higher urinary excretion of potassium is associated with higher intake of foods rich in potassium.

Where does this leave us for the prevention of diabetes and its complications? You guessed it: lifestyle modifications, the tried and true! Lifestyle should be the cornerstone, including diet, stress reduction and exercise, or at least mild to moderate physical activity.

References:

(1) Diabetes Care, online Nov. 17, 2015. (2) cdc.gov. (3) Diabetes Care. online Dec. 1, 2015. (4) JAMA Surg. online Sept. 16, 2015. (5) Ann Intern Med. 2015;163(11):861-868. (6) JAMA. 2012;308(6):581-590. (7) Clin J Am Soc Nephrol. online Nov 12, 2015.

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, go to the website www.medicalcompassmd.com or consult your personal physician.

Americans are very health conscious. Awareness of diet and nutrition is an important step. But does this awareness result in better health? This is the question we will attempt to answer.

We tend to focus on macronutrients commonly known as “the big three,” fat, protein and carbohydrates. You would think there could only be a finite number of diets and nutrition plans. In fact, it may be more complex than we think.

Let’s look at some recent developments and see how they impact our health.

Carbohydrates: Where are we with sugar?

Sugar is a major component of our diet, especially added sugar. Added sugar involves refined and unrefined types. The obvious ones are white and brown sugar, high fructose corn syrup, cane sugar and raw sugar. Less obvious ones are honey, agave and maple syrup. Then there is extracted sugar, which includes fruit juice and juice concentrate.

The good news is that per capita soda consumption has decreased by roughly one-quarter over the last 15 years, from 40 to 30 gallons per year. The best part is that water seems to be the substitute (1). Orange juice consumption has decreased even more by a whopping 45 percent over a similar time frame (2). Sales of sugary cereals have also seen a significant drop, according to the NPD group, a consumer research organization (3).

These are all encouraging sugar
consumption statistics, but what do they really mean?

According to a recent study, when
researchers reduced the amount of sugar consumed by obese children for 10 days, they saw dramatic, positive effects (4). There were decreases in both cholesterol and blood pressure readings, with the most substantial drops in triglyceride and blood sugar levels.

The study design was clever.
Researchers replaced substantial amounts of added sugar in their diet with other carbohydrates, so that no more than 10 percent of their diet was from added sugar. Calorie intake remained roughly the same. As a result, the children did not lose much weight, therefore reducing the influence of weight on the results.

There were 43 children who were 9 to 18 years old involved in this study, with a mean at the beginning of the study of 27 percent added sugar in their diets. These children were at high risk for diabetes and were considered initially to have metabolic syndrome, a compilation of increased waist circumference from visceral (belly) fat and borderline blood sugar, cholesterol and blood pressure levels. These are encouraging results, though this was a very short study. It is amazing what dietary changes can do in a very short time period.

Committee recommendations

Interestingly, the Dietary Guidelines Advisory Committee (DGAC), which influences USDA recommendations, suggested that Americans garner no more than 10 percent of our diet from added sugars. This would equal roughly 12 teaspoons of added sugar a day, as opposed to our current 22-30 teaspoons daily (5). Whole fruit does not count as an added sugar. Note that this was the same standard used in the study above with adolescents and teenagers. They also recommended cutting down on saturated fats and salt. We should be eating more fruit, vegetables, fish, nuts and whole grains.

With the influence from research findings of the DGAC, the FDA has proposed a similar recommendation of no more than 10 percent of the diet from added sugars (6). It also wants to update nutrition labels to differentiate between added sugars and naturally occurring sugars.

The American Heart Association and the World Health Organization recommend even stricter guidelines of less than half of the DGAC’s.

The more obvious foods with added sugar are sweets, while the less obvious are whole grain breads, low-fat yogurts, granola, salad dressings and sauces including pasta sauces and condiments.

Fats: Does it matter which type?

Saturated fat has been hotly debated as to whether it is harmful or neutral. In a recent meta-analysis involving two large observation studies, the Nurses’ Health Study and the Professional Follow-up Study, results show that by consuming 5 percent less calories from saturated fat and replacing them with unsaturated fats, there was a significant reduction in heart disease risk (7). If polyunsaturated fatty acids (PUFA) were used, there was a 25 percent reduction; if monounsaturated fatty acids (MUFA) were used, there was a 15 percent reduction. And if whole grains were used, there was a 9 percent reduction. Refined grains had no different effect than saturated fats. In fact, those who consumed the most refined grains, when compared to those who consumed the least, had a 10 percent increase in heart disease. There were 127,000 participants in this analysis who were not at high risk for heart disease at the study’s start. There was good duration of between 24 and 30 years.

Does the same benefit hold true for a low-fat diet?

In a meta-analysis involving 53 randomized controlled trials, including weight loss, weight maintenance and non-weight loss trials, results showed that low-fat diets do not help patients lose weight more than low-carbohydrate diets nor moderate- to high-fat diets (8). However, there are several weaknesses with this meta-analysis. For one, there was great variability among the trials, making it difficult to compare and combine results. The definition of low-fat was very broad. Also, most people have difficulty maintaining a low-fat diet, especially one with less than 20 percent of daily intake from fats.

I don’t think you can reduce one macronutrient in isolation and expect to see results for the population at large for the long term. This doesn’t mean that a low-fat diet may not work for you. But, of course, more studies and better studies with longer duration are needed.

Where are we with red meat?

The International Agency for
Research on Cancer (IARC), the cancer agency of the World Health Organization, has classified processed meats such as bacon, cold cuts and sausage as carcinogenic and red meat as possibly carcinogenic as it relates to colorectal cancer (9). The overall sentiment was to reduce the amount of consumption of processed and red meats. The research was based on mainly large observational studies of 20 years’ duration or longer.

Overall food study index

Finally, the really good news. By using the Alternate Healthy Eating Index 2010, researchers are able to evaluate how we are doing with our diets. We have reduced premature deaths from chronic disease, such as heart disease, diabetes and cancer, by approximately 1.1 million over roughly the last 15 years (10).

The reason, the researchers hypothesize, is mainly the removal of trans-fats, sugary beverages and red meat from our diets and the addition of fruits, vegetables, polyunsaturated fatty acids and whole grains. Our diet index has improved from 39.9 to 48.2. However, the top score is 110. There still is a long way to go to reach ideal levels.

Consequences

Though we have improved our diets, according to the index study, it is not enough. There is still a rise in the rate of obesity but for the first time diabetes rates have declined. For most of us, we need a dietary overhaul, not just to reduce one component or add another. Remember, not all calories are created equal, nor are all bodies created equal. So let’s stop trying to find one diet for every body.

References:

(1) cspinet.org. (2) https://store.mintel.com. (3) NPD.com. (4) Obesity (Silver Spring). Online Oct. 26, 2015. (5) health.gov. (6) FDA.gov. (7) J Am Coll Cardiol 2015; 66:1538-1548. (8) Lancet Diabetes Endocrinol. 2015;3(12):968-79. (9) Lancet Oncol.online Oct. 23, 2015. (10) Health Aff (Millwood). 2015;34(11):1916-1922.

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, go to the website www.medicalcompassmd.com or consult your personal physician.