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David Dunaief

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Rheumatoid arthritis causes pain, stiffness and swelling of the joints.

By David Dunaief, M.D.

Rheumatoid arthritis (RA) is one of many autoimmune diseases where the body’s immune system begins to attack the body’s own tissue. RA results in systemic (throughout the body) inflammation, which initially affects the synovium (lining) of the small joints in both the hand and the feet bilaterally, as well as the wrists and ankles (1). It causes pain, stiffness and swelling of the joints.

RA, like most autoimmune diseases, affects significantly more women than men and can be incredibly debilitating (2). It affects approximately 1 percent of the U.S. population (3). Fortunately, treatments have helped to significantly improve sufferers’ quality of life.

Dr. David Dunaief
Dr. David Dunaief

RA may be treated initially with acetaminophen and NSAIDs (such as ibuprofen), depending on its severity. To help stop progression and preserve the joints, disease-modifying anti-rheumatic drugs (known as DMARDs) may be used. They are considered the gold standard of treatment for RA and include methotrexate, which has been around the longest and is a first-line therapy; plaquenil (hydroxycholorquine); and TNF inhibitors, such as Enbrel (etanercept), Humira (adalimumab) and Remicade (infliximab).

DMARDs work by reducing inflammation and acting as immunosuppressives, basically tamping down or suppressing the immune system. These drugs have helped RA patients improve their quality of life, preserving joint integrity and causing RA to go into remission. The goal of these drugs is to reduce synovitis, or inflammation in the joints, helping to lessen joint damage. They can be quite effective. Unfortunately, compliance can be an issue. In addition, corticosteroids can be used to suppress inflammation.

The yin and yang of medications

In a meta-analysis (a group of 28 studies), the results showed that DMARDs reduced the risk of cardiovascular events by up to 30 percent, while NSAIDs and corticosteroids increased the risk (4). However, oral steroids have been found to increase the risk of heart complications, approximately a 50 percent rise in risk. This may be one reason rheumatologists encourage their RA patients to discontinue oral steroid treatments as quickly as possible.

In an observational study, the results reaffirmed that corticosteroids increased the risk of a heart attack in RA patients, this time by 68 percent (5). The study involved over 8,000 patients with a follow-up of nine years. Interestingly, there was a dose-response curve. In other words, the results also showed that for every 5-mg increase in dosage, there was a corresponding 14 percent increase in heart attack risk.

The downside of using immunosuppressive drugs

Unfortunately, DMARDs have significant adverse effects. In 2011, the FDA found there were 100 cases of Listeria and Legionella pneumonia infections associated with these drugs. Therefore, a black-box warning was placed on all TNF inhibitors cautioning about serious or life-threatening side effects, such as opportunistic infections — more likely in combination with other immunosuppressives — and malignancy. The median duration that patients were on the drugs when they experienced infections was about 10 months. However, most patients were also on methotrexate and steroids at the time of infection.

Anecdotally, I had a patient who had previously developed pneumonia twice, multiple basal-cell carcinomas and one episode of melanoma. These were all attributed to use of a TNF inhibitor.

Skin cancer risk

In 2009, the FDA warned that there is an increased risk of cancer after about 30 months of treatment, especially with TNF inhibitors. A 2011 meta-analysis (a group of 28 studies) found that TNF inhibitors may increase the risk of cancers, including skin cancers (6). In four of the studies, there was a 45 percent elevated risk of developing skin cancer other than melanoma. However, in data pooled from two of the studies, there was a 79 percent greater chance of developing melanoma. All the studies in this analysis were observational studies, and the absolute risk of developing cancer is small. The good news is that this analysis did not appear to show increased risk of lymphoma.

Cardiovascular disease

Patients with RA are at a threefold increased risk of developing coronary artery disease, compared to the general population (7). Those RA patients who stopped taking statins for high cholesterol and/or heart disease had a 60 percent increased risk of cardiovascular mortality and a 79 percent increased risk of all-cause death after three months (8). Though statins have their pitfalls, they can be potentially lifesaving in the right context. Don’t discontinue statins before consulting your physician.

Additional complications from RA

RA can also affect organs and the surrounding tissue. Thus, complications from RA include heart disease, stroke, atrial fibrillation, chronic obstructive pulmonary disease, fracture risk, as well as uveitis and scleritis (inflammatory disorders of the eye).

Nonpharmacologic approaches

Exercise and fish oil have shown reductions in symptomatology and joint inflammation. In a meta-analysis (a group of 17 trials), omega-3 fish oil reduced joint pain intensity, as reported by patients, minutes of morning stiffness, number of painful joints and NSAID use significantly (9). The dose was at least 2.7 g of EPA plus DHA in the omega-3 fish oil and took at least 12 weeks of treatment to see a benefit. Exercise is also important to relieve joint pain and stiffness. In a meta-analysis of 14 studies, there was a 69 percent reduction in pain with aerobic exercise (10). Understandably, however, a study found that 42 percent of RA patients don’t work out at the recommended minimum of 10 minutes of moderate exercise daily (11). The reasons were that half were either not motivated or believed that exercise had no benefit.

Prevention

In the Iowa Women’s Health Study, results showed that supplemental vitamin D decreased the risk of RA by 34 percent (12). This study involved almost 30,000 women followed over an 11-year period.

The best way to treat an autoimmune disease like rheumatoid arthritis is to prevent it with an anti-inflammatory diet, exercise and omega-3 fish oil. Barring that, however, it is encouraging that DMARD treatments may be effective at half the dose once the disease has been suppressed significantly. Therefore, a low-dose pharmacological approach coupled with nonpharmacological lifestyle adjustments may produce the best outcomes with the fewest adverse reactions.

References: (1) www.ncbi.nlm.nih.gov. (2) www.mayoclinic.com. (3) Arthritis Rheum. 2008;58:15-25. (4) Ann Rheum Dis 2015;74(3):480-489. (5) Rheumatology 2013;52:68-75. (6) Ann Rheum Dis. 2011 Nov;70(11):1895-1904. (7) Ann Rheum Dis. 2007;66(1):70. (8) Arthritis Care Res [Hoboken]. 2012 Mar 29. (9) Pain. 2007 May;129(1-2):210-223. (10) Br J Sports Med. 2011;45(12):1008-1009. (11) Arthritis Care Res [Hoboken]. 2012 Apr;64(4):488-493. (12) Arthritis Rheum. 2004 Jan;50(1):72-77.

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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Consuming white fleshy fruits such as pears may decrease ischemic stroke risk by as much as 52 percent.

By David Dunaief, M.D.

Stroke remains one of the top five causes of mortality and morbidity in the United States (1). As a result, we have a wealth of studies that inform us on issues ranging from identifying chronic diseases that increase stroke risk to examining the roles of medications and lifestyle in managing risk.

Impact of chronic diseases

There are several studies that show chronic diseases — such as age-related macular degeneration, rheumatoid arthritis and migraine with aura — increase the risk for stroke. Therefore, patients with these diseases must be monitored.

In the ARIC study, stroke risk was approximately 50 percent greater in patients who had AMD compared to those who did not — 7.6 percent versus 4.9 percent, respectively (2). This increase was seen in both types of stroke: ischemic (complete blockage of blood flow in the brain) and hemorrhagic (bleeding in the brain). The risk was greater for hemorrhagic stroke than for ischemic, 2.64 vs. 1.42 times increased risk.

However, there was a smaller overall number of hemorrhagic strokes, which may have skewed the results. This was a 13-year observational study involving 591 patients, ages 45 to 64, who were diagnosed with AMD. Most patients had early AMD. If you have AMD, you should be followed closely by both an ophthalmologist and a primary care physician.

Rheumatoid arthritis (RA)

In an observational study, patients with RA had a 30 percent increased risk of stroke, and those under 50 years old with RA had a threefold elevated risk (3). This study involved 18,247 patients followed for a 13-year period. There was also a 40 percent increased risk of atrial fibrillation (AF), a type of arrhythmia or irregular heartbeat. Generally, AF causes increased stroke risk; however, the authors were not sure if AF contributed to the increased risk of stroke seen here. They suggested checking regularly for AF in RA patients, and they surmised that inflammation may be an underlying cause for the higher number of stroke events.

Migraine with aura

In the Women’s Health Study, an observational study, the risk of stroke increased twofold in women who had migraine with aura (4). Only about 20 percent of migraines include an aura, and the incidence of stroke in this population is still rather rare, so put this in context (5).

Medications with beneficial effects

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (6). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (7).

It is important to recognize that chronic disease increases stroke risk. High blood pressure and high cholesterol are two of the most significant risk factors. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Medication combination: negative impact

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (8, 9).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day — an adult dose — it would result in 900,000 major bleeding events per year (10).

Lifestyle modifications

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (11). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (12). The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s important role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (13). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — low-dose aspirin — since the risk of a second stroke is high.

References: (1) cdc.gov. (2) Stroke online April 2012. (3) BMJ 2012; Mar 8;344:e1257. (4) Neurology 2008 Aug 12; 71:505. (5) Neurology. 2009;73(8):576. (6) AAN conference: April 2012. (7) Am J Cardiol 2012; 109(9):1308-1314. (8) ISC 2012; Abstract LB 9-4504; (9) www.clinicaltrials.gov NCT00059306. (10) JAMA 2007;297:2018-2024. (11) Stroke. 2011; 42: 3190-3195. (12) J. Nutr. 2011;141(8):1552-1558. (13) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

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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By David Dunaief, M.D.

David Dunaief, M.D.
David Dunaief, M.D.

Many of us give thanks for our health on Thanksgiving. Well, let’s follow through with this theme. While eating healthy may be furthest from our minds during a holiday, it is so important. Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain and fatigue, as well as increase your risk for chronic diseases, you can reverse this trend while staying in the traditional theme of what it means to enjoy a festive meal.

What can we do to turn Thanksgiving into a bonanza of good health? Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. Carotenoids make up a family of greater than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (1).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer; amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease; age-related macular degeneration; and cardiovascular disease — heart disease and stroke. Foods that contain these substances are orange, yellow and red vegetables and fruits and dark green leafy vegetables. Examples include sweet potato, acorn squash, summer squash, spaghetti squash, green beans, carrots, cooked pumpkin, spinach, kale, papayas, tangerines, tomatoes and Brussels sprouts.

Acorn squash contains carotenoids, which help to prevent breast cancer, Lou Gehrig’s disease, age-related macular degeneration and cardiovascular disease.
Acorn squash contains carotenoids, which help to prevent breast cancer, Lou Gehrig’s disease, age-related macular degeneration and cardiovascular disease.

Let’s look at the evidence.

Breast cancer effect

We know that breast cancer risk is high among women, especially on Long Island. The risk for a woman getting breast cancer is 12.4 percent in her lifetime (2). Therefore, we need to do everything within reason to reduce that risk. In a meta-analysis (a group of eight prospective or forward-looking studies), results show that women who were in the second to fifth quintile blood levels of carotenoids, such as alpha-carotene, beta-carotene and lutein and zeaxanthin, had significantly reduced risk of developing breast cancer (3). Thus, there was an inverse relationship between carotenoid levels and breast cancer risk. Even modest amounts of carotenoids potentially can have a resounding effect in preventing breast cancer.

ALS: Lou Gehrig’s disease

ALS is a disabling and feared disease. Unfortunately, there are no effective treatments for reversing it. Therefore, we need to work double-time in trying to prevent its occurrence. In a meta-analysis of five prestigious observational studies, including The Nurses’ Health Study and the Health Professionals Follow-Up Study, results showed that people with the greatest amount of carotenoids in their blood from foods such as spinach, kale and carrots had a decreased risk of developing ALS and/or delayed the onset of the disease (4). This study involved over one million people with more than 1,000 who developed ALS.

Those who were in the highest carotenoid level quintile had a 25 percent reduction in risk, compared to those in the lowest quintile. This difference was even greater for those who had high carotenoid levels and did not smoke; they achieved a 35 percent reduction. According to the authors, the beneficial effects may be due to antioxidant activity and more efficient function of the power source of the cell, the mitochondrion. This is a good way to prevent a horrible disease while improving your overall health.

Positive effects of healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are several obstacles to healthy eating. Two critical factors are presentation and perception. Presentation is glorious for traditional dishes, like turkey, gravy and stuffing with lots of butter and creamy sauces. However, vegetables are usually prepared in either an unappetizing way — steamed to the point of no return, so they cannot compete with the main course, or smothered in cheese, negating their benefits, but clearing our consciences.

Many consider Thanksgiving a time to indulge and not think about the repercussions. Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. Why is it so important to change our mind-sets? Believe it or not, there are significant short-term consequences of gorging ourselves. Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when most gain the predominant amount of weight for the entire year.

However, people do not lose the weight they gain during this time (5). If you can fend off weight gain during the holidays, just think of the possibilities for the rest of the year. Also, if you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (6). However, with a little Thanksgiving planning, you can reap significant benefits.

What strategies should you employ for the best outcomes?

• Make healthy, plant-based dishes part of the main course. I am not suggesting that you forgo signature dishes, but add to tradition by making mouthwatering vegetable-based main dishes for the holiday.

• Improve the presentation of vegetable dishes. Most people don’t like grilled chicken without any seasoning. Why should vegetables be different? In my family, we make sauces for vegetables, like a peanut sauce using mostly rice vinegar and infusing a teaspoon of toasted sesame oil. Good resources for appealing dishes can be found at www.pcrm.org, EatingWell magazine, www.wholefoodsmarket.com and many other resources.

• Replace refined grains with whole grains. A study in the American Journal of Clinical Nutrition showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (7). Not only did participants lose subcutaneous fat found just below the skin but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer.

• Create a healthy environment. Instead of putting out creamy dips, processed crackers and candies as snacks prior to the meal, put out whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.

• Offer more healthy dessert options, like dairy-free pumpkin pudding and fruit salad. The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods. You don’t have to be perfect, but improvements during this time period have a tremendous impact — they set the tone for the new year and put you on a path to success. Why not turn this holiday into an opportunity to de-stress, rest and reverse or prevent chronic disease by consuming plenty of carotenoid-containing foods.

References: (1) Crit Rev Food Sci Nutr 2010;50(8):728–760. (2) SEER Cancer Statistics Review, 1975–2009, National Cancer Institute. (3) J Natl Cancer Inst 2012;104(24):1905-1916. (4) Ann Neurol 2013;73:236–245. (5) N Engl J Med 2000; 342:861-867. (6) www.heart.org. (7) Am J Clin Nutr 2010 Nov; 92(5):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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Vitamin D levels may play an important role in the treatment of multiple sclerosis.

By David Dunaief, M.D.

David Dunaief, M.D.
David Dunaief, M.D.

Medicine has made great strides in the treatment of multiple sclerosis over the last few decades. Multiple sclerosis (MS) is an autoimmune disease where there is underlying inflammation and the immune system attacks its own tissue. This causes demyelination, or breakdown of the myelin sheath, a protective covering on the nerves in the central nervous system (CNS). The result is a number of debilitating effects, such as cognitive impairment, numbness and weakness in the limbs, fatigue, memory problems, inflammation of the optic nerve causing vision loss and eye pain (optic neuritis) and mobility difficulties.

There are several forms of MS. The two most common are relapsing-remitting and primary-progressive. Relapsing-remitting has intermittent flare-ups and occurs about 85 to 90 percent of the time. Primary-progressive (steady) occurs about 10 percent of the time. Relapsing-remitting may eventually become secondary-progressive MS, which is much harder to control, although dietary factors may play a role.

Diagnosis and progression

MS is diagnosed in several ways. The ophthalmologist may be the first to diagnose the disease with a retinal exam (looking at the back of the eye). If you have eye pain or sudden vision loss in one eye, it is important to see your ophthalmologist. Another tool in diagnosis is an MRI of the CNS. This looks for lesions caused by the breakdown of the myelin sheath. The MRI can also be used to determine the risk of progression from a solitary CNS lesion to a full-blown MS diagnosis. This is accomplished by examining the corpus callosum, a structure deep within the brain, according to a presentation at the European Neurologic Society (1). Approximately half of patients with one isolated lesion will progress to clinically definite MS within six years. An MRI may be able to predict changes in this portion of the brain within two years. Patients with a family history of MS should discuss this diagnostic with a neurologist.

Medication

Interferon beta is the mainstay of treatment for MS for good reason. Data shows that it reduces recurrence in relapsing-remitting MS and also the number of brain lesions.However, in a study, interferon beta failed to stop the progression to disability in the long term (2). Many MS patients will experience disability over 20 years. Ultimately, what does this mean? Patients should continue therapy; however, they should have realistic expectations. This study was retrospective, looking back at previously collected data — not the strongest of studies.

In an RCT, higher levels of vitamin D in the blood showed a trend toward reduced disability in timed tandem walking and in disability accumulation.

Vitamin D impact

Vitamin D may play a key role in reducing flare-ups in relapsing-remitting MS. There have been several studies that showed this benefit with vitamin D supplements and/or with interferon beta. In one study, interferon beta had very interesting results showing that it may help increase the absorption of vitamin D from the sun (3). This was a randomized controlled trial (RCT), the gold standard of studies, involving 178 patients. The study’s authors suggest that interferon beta’s effectiveness at reducing the frequency of relapsing-remitting MS flare-ups may have to do with its effect on the metabolizing of vitamin D. In those who did not have higher blood levels of vitamin D, interferon beta actually increased the risk of flare-ups.

Physicians should monitor blood levels of vitamin D to make sure they are adequate. It may be beneficial for MS patients to get 15 to 20 minutes of sun exposure without sunscreen per day. However, patients with a history of high risk of skin cancer should not be in the sun without protective clothing and sunscreen.

In a prospective (forward-looking) observational study, patients with higher levels of vitamin D, even in those without interferon beta treatment, had reduced risk of relapsing-remitting MS flare-ups (4). The patients with higher levels had 40 ng/ml, and those with lower levels had 20 ng/ml. Patients’ blood samples were assessed every eight weeks for a mean duration of 1.7 years. The relationship with vitamin D was linear — as the blood level increased two-fold, the risk of flare-ups decreased by 27 percent.

In an RCT, higher levels of vitamin D in the blood showed a trend toward reduced disability in timed tandem walking and in disability accumulation (5). The results did not reach statistical significance, but approached it. A much larger RCT needs to be performed to test for significance.

Diet and lifestyle

Interestingly, a study found that caffeine, alcohol and fish — fatty or lean — intake may result in delay of secondary progression of relapsing-remitting MS (6). This observational study involved 1,372 patients. The reduction in risk of disability was as follows: Moderate daily alcohol intake resulted in a 39 percent reduction; daily coffee consumption showed a 40 percent reduction; and fish two or more times a week showed a 40 percent reduction.

All of these results were compared to patients who did not consume these items. However, the same effect was not shown in primary-progressive MS patients: Fatty fish actually increased risk of progression, compared to lean fish. With MS, vitamin D blood levels may be critically important. They are one of the easier fixes, although it may take higher doses of vitamin D supplementation to reach sufficient levels, once low.

While food (fish with bones, for example) provides vitamin D, it falls short of the amount needed by an MS patient. Interferon beta and vitamin D supplementation may have added effects. Lifestyle changes or additions also have tantalizingly appealing possibilities.

References: (1) Abstract O-293; June 2012. (2) JAMA. 2012;308:247-256. (3) Neurology. 2012;79:208-210. (4) Neurology. 2012;79:254-260. (5) J Neurol Neurosurg Psychiatry. 2012;83(5):565-571. (6) Eur J Neurol. 2012 Apr;19(4):616-624.

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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By Dr. David Dunaief

Prostate cancer is the second most common cancer in men, after skin cancer. The American Cancer Society estimates that, in 2016, there will be almost 190,000 new prostate cancer diagnoses in the United States and just over 26,000 deaths (1). What better time to discuss prostate cancer prevention than in “Movember,” a month dedicated to raising awareness of men’s health issues?

The best way to avoid prostate cancer is through lifestyle modifications, which means garnering knowledge about both detrimental and beneficial approaches. There are a host of things that may increase your risk and others that may decrease your likelihood of prostate cancer. Your genetics or family history do not mean you can’t alter gene expression with the choices you make.

What may increase the risk of prostate cancer? Contributing factors include obesity, animal fat and supplements, such as vitamin E and selenium. Equally as important, factors that may reduce risk include vegetables, especially cruciferous, tomato sauce or cooked tomatoes, soy and even coffee.

Vitamin E and selenium

In the SELECT trial, a randomized clinical trial (RCT), a dose of 400 mg of vitamin E actually increased the risk of prostate cancer by 17 percent (2). Though significant, this is not a tremendous clinical effect. It does show that vitamin E should not be used for prevention of prostate cancer. Interestingly, in this study, selenium may have helped to reduce the mortality risk in the selenium plus vitamin E arm, but selenium trended toward a slight increased risk when taken alone. Therefore, I would not recommend that men take selenium or vitamin E for prevention.

Obesity

Obesity showed conflicting results, prompting the study authors to analyze the results further. According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer, however increase risk of aggressive disease (3). Don’t think this means that obesity has protective effects. It’s quite the contrary. The authors attribute the lower incidence of nonaggressive prostate cancer to the possibility that it is more difficult to detect the disease in obese men, since larger prostates make biopsies less effective. What the results tell us is that those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Animal fat, red meat and processed meats

It seems there is a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, a large observational study, those who consumed the highest amount of animal fat had a 63 percent increased risk, compared to those who consumed the least. Here is the kicker: It was not just the percent increase that was important, but the fact that it was an increase in advanced or metastatic prostate cancer (4). Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you are going to eat red meat, I recommend decreased frequency, like lean meat once every two weeks or once a month.

In another large, prospective (forward-looking) observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (5).

Omega-3s paradox

When we think of omega-3 fatty acids or fish oil, we think “protective” or “beneficial.” However, these may increase the risk of prostate cancer, according to one epidemiological study (6). This study, called the Prostate Cancer Prevention Trial, involving a seven-year follow-up period, showed that docosahexaenoic acid (DHA), a form of omega-3 fatty acid, increased the risk of high-grade disease 2.5-fold. This finding was unexpected.

However, this does not mean that men should cut back on fish consumption; the effects of omega-3s on heart disease prevention are significant, and heart disease is far more prevalent. Also, this is only one study finding. If you choose to eat fish, salmon or sardines in water with no salt are among the best choices.

Lycopene — found in tomato sauce

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown beneficial effects. This may be because, in order to release lycopene, the tomatoes need to be cooked (7). It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit.

In a prospective (forward-looking) study involving 47,365 men who were followed for 12 years, the risk of prostate cancer was reduced by 16 percent (8). The primary source of lycopene in this study was tomato sauce. When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

In the Health Professionals Follow-Up Study, the results were similar, with a 21 percent reduction in the risk of prostate cancer (9). Again, tomato sauce was the predominant food responsible for this effect. This was another large observational study with 47,894 participants. Although tomato sauce may be beneficial, many brands are loaded with salt. I recommend to patients that they either make their own sauce or purchase a sauce with no salt, such as one made by Eden Organics.

Vegetable effect

Vegetables, especially cruciferous vegetables, reduce the risk of prostate cancer significantly. In a case-control study (comparing those with and without disease), participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (10). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

Where does coffee fit in?

Surprisingly, coffee may reduce the risk of prostate cancer. It was recently shown in the Health Professionals Follow-Up Study, where there was a dose-response curve. In other words, the more coffee consumed, the lower the risk. Even those who consumed one to three cups a day saw a 30 percent reduction in the risk of lethal prostate cancers, whether the coffee was caffeinated or decaffeinated (11). Coffee contains bioactive compounds, such as phenolic acids, which have antioxidant effects.

There is a caveat. Although, in this study, more was better, that is not always true in many other studies. Therefore, I would not recommend drinking more than three cups per day, because of other potentially detrimental effects. I think it is apt to finish with two thoughts. Aaron Katz, M.D., from Columbia University Medical Center, had it right when he mentioned that lifestyle modification was important. He was talking about those with early-stage prostate cancer. However, the same philosophy can be applied to prevention of prostate cancer. My goal in writing this article was to arm you with the knowledge you need to start protecting yourself or your loved ones today.

References: (1) www.cancer.org. (2) JAMA. 2011; 306: 1549-1556. (3) Epidemiol Rev. 2007;29:88. (4) J Natl Cancer Inst. 1993;85(19):1571. (5) Am J Epidemiol. 2009;170(9):1165. (6) Am J Epidemiol. 2011 Jun 15;173(12):1429-1439. (7) Exp Biol Med (Maywood). 2002; 227:914-919. (8) J Natl Cancer Inst. 2002;94(5):391. (9) Exp Biol Med (Maywood). 2002; 227:852-859; Int. J. Cancer. 2007;121: 1571–1578. (10) J Natl Cancer Inst. 2000;92(1):61. (11) J Natl Cancer Inst. 2011;103:876-884.

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

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Statin users tend to neglect dietary guidance.

By David Dunaief, M.D.

High cholesterol affects a great number of Americans and cuts across many demographics, affecting young and old and those in between. When we think of hyperlipidemia (high cholesterol), what do you think is the mainstay of medical treatment? If you said “statins” you would be correct.

Do statins deserve this central role in treatment? They have been convincingly shown in studies to significantly lower cholesterol, and they play an important role for those who have cardiovascular disease. However, should we be using statins as liberally as we have? Well, guidelines for the treatment of high cholesterol, released in November 2013, suggest that we should. In fact, if followed, these guidelines would increase the use of this medication, especially in those over the age of 60. Some in the medical community have even joked that statins might as well be put in the drinking water.

This is a medication that patients may be on for life. I don’t know about you, but that thought sends chills down my spine. We know all medications have pros and cons. Statins are no exception; they have been mired in controversy. For one thing, they have side effects. These include possibly increasing the risks of diabetes, myalgias (muscle pain), hepatic (liver) toxicity, kidney disorders and negatively affecting memory.

Statins also may reduce the benefits of exercise, and they may not be as effective in women as they are in men. Because statins are such effective cholesterol-lowering medications, does this mean that patients on these drugs may become complacent with their diets? A new study indicates that this is exactly what might be happening. Let’s look at the evidence.

Statins have been mired in controversy. Stock photo
Statins have been mired in controversy. 

Diet complacency

The “S” in statins does not stand for “superimmune to eating anything.” In a study published in JAMA Internal Medicine, results show that those who are taking statins tend to eat more calories and fats and, ultimately, increase their [body mass index] by gaining weight compared to those who were not taking statins (1).

In fact, in this study that used 11 years of NHANES data, results showed that there were a 14 percent increase in fat intake and an almost 10 percent increase in overall calorie intake among statin users. This resulted in a BMI that rose by 1.3 percent in those on statins, while in nonusers over the same period BMI only rose by 0.4 percent.

In other words, if you took an average male who was 5 feet 9 inches and weighed 200 lb, the difference between statin users and nonusers would be the difference between obesity and being just below obesity. Those on statins were consuming about 200 extra calories a day. This increase in calorie consumption occurred after they were placed on statins. Their weight also increased by 6.6 to 11 lb. This is especially concerning to the researchers, since the guidelines for statin use call for a prudent diet to help reduce fat and calorie intake with the ultimate goal of reducing weight.

However, the opposite was found to have happened — users consumed more calories and gained more weight. This is an observational study with over 27,000 participants, therefore no firm conclusions can be made. However, statins are not a license to gorge at the all-you-can-eat buffet line. We already know that statins may increase the risk of diabetes. Why worsen this risk with dietary indiscretions that are harmful to your BMI?

As an aside, the authors note that this increased calorie and fat consumption may be a contributing reason for the increased risk of diabetes with statins, but it’s too early to tell.

Impact on women

We tend to clump data together from trials that focus predominantly on one demographic, in this case men, and apply the results broadly to both men and women. However, in a May 5, 2014, New York Times article, “A New Women’s Issue: Statins,” some in the medical community, including the editor of JAMA, focus attention on this tendency, noting that this may be a mistake (2).

According to the dissenters, the thought process is that women have been underrepresented in statin trials, and cholesterol may not play the same role in women as it does in men. Yet almost half of the patients treated with statins are women. These physicians were referring to the use of statins in primary prevention, or in those who have high cholesterol but who do not have documented heart disease.

Lest you think their views are based solely on opinion or anecdotal data from clinical experience, this data on women was from the JUPITER trial, which looked at almost 7,000 initially healthy female participants (3). Statins did benefit women by reducing the occurrence of chest pain and reducing the number of stent placements and bypass surgeries, but they did not reach the primary end points of showing statistical significance in reducing the occurrence of a first heart attack, stroke or death.

The caveat is that there were not a large number of cardiovascular events — heart attacks, strokes or death — that occurred in either the treatment group or the control group. These results were in women over the age of 60. This may give slight pause when prescribing statins. By no means do I think these physicians are advocating to not give women statins, just that we may want to weigh the benefits and risks on a case-by-case basis.

Tamping down exercise benefits

If exercise is beneficial for lowering cardiovascular disease risk and so are statins, the logical presumption might be that the two together would create a synergistic effect that is greater than the two alone — or at least an added benefit from combining the two. Unfortunately, what seems straightforward is not always the case.

In a small, yet randomized controlled trial, participants who were put on statins and monitored for cardiopulmonary exercise saw a blunted aerobic effect compared to the control group, which exercised without the medication (4). In the treatment group, there was a marginal 1.5 percent improvement with aerobic exercise, while the control group experienced a much more robust 10 percent gain.

The reason for this disappointing discrepancy is that statins seem to interrupt the enzymes that are responsible for making the mitochondria (the powerhouse or energy source for the cell) more efficient. The most troubling aspect of this trial is that the participants chosen were out-of-shape, overweight individuals in need of aerobic exercise.

Whether or not a patient, male or female, is placed on cholesterol-lowering medication, one thing is clear: There is a strong need to make sure that lifestyle modifications are always emphasized to help reduce the risk of cardiovascular disease to its lowest levels. But the quandary becomes what to do with statins and exercise. And statins, as powerful and effective as they may be, still do have side effects, may reduce exercise benefits and may not have the same effects for women. Thus, they may not be appropriate for everyone. A healthy diet and exercise, however, are appropriate for all.

References: (1) JAMA Intern Med. online April 24, 2014. (2) nytimes.com. (3) N Engl J Med. 2008 Nov 20;359(21):2195-2207. (4) J Am Coll Cardiol. 2013;62(8):709-714.

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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A diet rich in fruits, vegetables, beans, nuts and oily fish may prevent breast cancer. Stock photo

By David Dunaief, M.D.

NFL players are wearing pink shoes and other sportswear this month, making a fashion statement to highlight Breast Cancer Awareness Month. This awareness is critical since annual invasive breast cancer incidence in the U.S. is 246,000 new cases, with approximately 40,000 patients dying from this disease each year (1). The good news is that from 1997 to 2008 there was a trend toward decreased incidence by 1.8 percent (2).

We can all agree that screening has merit. The commercials during NFL games tout that women in their 30s and early 40s have discovered breast cancer with a mammogram, usually after a lump was detected. Does this mean we should be screening earlier? Screening guidelines are based on the general population that is considered “healthy,” meaning no lumps were found, nor is there a personal or family history of breast cancer.

All guidelines hinge on the belief that mammograms are important, but at what age? Here is where divergence occurs; experts can’t agree on age and frequency. The U.S. Preventive Services Task Force recommends mammograms starting at 50 years old, after which time they should be done every other year (3). The American College of Obstetricians and Gynecologists recommends mammograms start at 40 years old and be done annually (4). Your decision should be based on a discussion with your physician.

The best way to treat breast cancer — and just as important as screening — is prevention, whether it is primary, preventing the disease from occurring, or secondary, preventing recurrence. We are always looking for ways to minimize risk. What are some potential ways of doing this? These may include lifestyle modifications, such as diet, exercise, obesity treatment and normalizing cholesterol levels. Additionally, although results are mixed, it seems that bisphosphonates do not reduce the risk of breast cancer nor its recurrence. Let’s look at the evidence.

Bisphosphonates

Bisphosphonates include Fosamax (alendronate), Zometa (zoledronic acid) and Boniva (ibandronate) used to treat osteoporosis. Do they have a role in breast cancer prevention? It depends on the population, and it depends on study quality.

In a meta-analysis involving two randomized controlled trials, results showed there was no benefit from the use of bisphosphonates in reducing breast cancer risk (5). The population used in this study involved postmenopausal women who had osteoporosis, but who did not have a personal history of breast cancer. In other words, the bisphosphonates were being used for primary prevention.

The study was prompted by previous studies that have shown antitumor effects with this class of drugs. This analysis involved over 14,000 women ranging in age from 55 to 89. The two trials were FIT and HORIZON-PFT, with durations of 3.8 and 2.8 years, respectively. The FIT study involved alendronate and the HORIZON-PFT study involved zoledronic acid, with these drugs compared to placebo. The researchers concluded that the data were not evident for the use of bisphosphonates in primary prevention of invasive breast cancer.

In a previous meta-analysis of two observational studies from the Women’s Health Initiative, results showed that bisphosphonates did indeed reduce the risk of invasive breast cancer in patients by as much as 32 percent (6). These results were statistically significant. However, there was an increase in risk of ductal carcinoma in situ (precancer cases) that was not explainable. These studies included over 150,000 patients with no breast cancer history. The patient type was similar to that used in the more current trial mentioned above. According to the authors, this suggested that bisphosphonates may have an antitumor effect. But not so fast!

The disparity in the above two bisphosphonate studies has to do with trial type. Randomized controlled trials are better designed than observational trials. Therefore, it is more likely that bisphosphonates do not work in reducing breast cancer risk in patients without a history of breast cancer or, in other words, in primary prevention.

In a third study, a meta-analysis (group of 36 post-hoc analyses — after trials were previously concluded) using bisphosphonates, results showed that zoledronic acid significantly reduced mortality risk, by as much as 17 percent, in those patients with early breast cancer (7). This benefit was seen in postmenopausal women but not in premenopausal women. The difference between this study and the previous study was the population. This was a trial for secondary prevention, where patients had a personal history of cancer.

However, in a RCT, the results showed that those with early breast cancer did not benefit overall from zoledronic acid in conjunction with standard treatments for this disease (8). The moral of the story: RCTs are needed to confirm results, and they don’t always coincide with other studies.

Exercise

We know exercise is important in diseases and breast cancer is no exception. In an observational trial, exercise reduced breast cancer risk in postmenopausal women significantly (9). These women exercised moderately; they walked four hours a week. The researchers stressed that it is never too late to exercise, since the effect was seen over four years. If they exercised previously, but not recently, for instance, five to nine years ago, no benefit was seen.

To make matters worse, only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. The NFL, which does an admirable job of highlighting Breast Cancer Awareness Month, should go a step further and focus on the importance of exercise to prevent breast cancer or its recurrence, much as it has done to help motivate kids to exercise with it Play 60 campaign.

Soy intake

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

Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk, when compared to those who consumed the least. Why have we not seen this in U.S. trials? The level of soy used in U.S. trials is a fraction of what is used in Asian trials. The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

Western vs. Mediterranean diets

A Mediterranean diet may decrease the risk of breast cancer significantly.
A Mediterranean diet may decrease the risk of breast cancer significantly.

In an observational study, results showed that, while the Western diet increases breast cancer risk by 46 percent, the Spanish Mediterranean diet has the inverse effect, decreasing risk by 44 percent (11). The effect of the Mediterranean diet was even more powerful in triple-negative tumors, which tend to be difficult to treat. The authors concluded that diets rich in fruits, vegetables, beans, nuts and oily fish were potentially beneficial.

Hooray for Breast Cancer Awareness Month stressing the importance of mammographies and breast self-exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a Mediterranean diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence.

References: (1) breastcancer.org. (2) J Natl Cancer Inst. 2011;103:714-736. (3) Ann Intern Med. 2009;151:716-726. (4) Obstet Gynecol. 2011;118:372-382. (5) JAMA Inter Med online. 2014 Aug. 11. (6) J Clin Oncol. 2010;28:3582-3590. (7) 2013 SABCS: Abstract S4-07. (8) Lancet Oncol. 2014;15:997-1006. (9) Cancer Epidemiol Biomarkers Prev online. 2014 Aug. 11. (10) Br J Cancer. 2008;98:9-14. (11) Br J Cancer. 2014;111:1454-1462.

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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Full-fat and low-fat cheeses are no better for you than refined grains. Stock photo

By David Dunaief, M.D.

We are constantly redefining or at least tweaking our diets. We were told that fats were the culprit for cardiovascular disease (CVD). That the root cause was saturated fats, specifically. However, a recent study showed the sugar industry had a strong influence on the medical and scientific communities in the 1960s and 1970s, influencing this perception (1).

Why is this all important? Well, for one thing, about one out every two “healthy” 30-year-olds in the United States will most likely develop CVD in their lifetime (2). This is a sobering statistic. For another, CVD is still the reigning notorious champion when it comes to the top spot for deaths in this country. Except, this disease is preventable, for the most part.

What can prevent CVD? You guessed it, lifestyle modifications, including changes in our diet, exercise and smoking cessation. There is no better demonstration of this than what I refer to as the “new” China Study, which was done through the Harvard T.H. Chan School of Public Health. I call it “new,” because T. Colin Campbell published a book in 2013 with the same name pertaining to the benefits of the Chinese diet in certain provinces. However, the wealthier China has become in the last few decades by opening its borders, the more it has adopted a Western hemisphere-type lifestyle, and the worse its health has become overall. In a recent study published in the Journal of the American College of Cardiology, results show that over 20 years the rate of CVD has increased dramatically in China, and it is likely to continue worsening over time (3). High blood pressure, elevated “bad” cholesterol LDL levels, blood glucose (sugars), sedentary lifestyle and obesity were the most significant contributors to this rise. In 1979 about 8 percent of the population had high blood pressure, but by 2010, more than one-third of the population did.

Does this sound familiar? It should, since this is due to adopting a Western-type diet. The researchers highlighted increased consumption of red meat and soda, an increasingly sedentary lifestyle and, unlike us, half the population still smokes. But you can see just how powerful the effects of lifestyle are on the world’s largest population. There were 26,000 people and nine provinces involved.

Cardiologist embraces fat

We are going to focus on one area, diet. What is the most productive diet for preventing cardiovascular disease? In a recent New York Times article, entitled “An Unconventional Cardiologist Promotes a High-Fat Diet,” published on Aug. 23, 2016, the British cardiologist suggests that we should embrace fats, including saturated fats (4). He has bulletproof coffee for breakfast, with one tablespoon of butter and one tablespoon of coconut oil added to his coffee. He also promotes full-fat cheese as opposed to low-fat cheese. These are foods that contain 100 percent saturated fats. He believes dairy can protect against heart disease. Before you get yourself in a lather, either in agreement or in disgust, let’s look at the evidence.

The Cheesy Study

Alert! Before you read any further, know that this study was sponsored by the dairy industry in Denmark. Having said this, this study would presumably agree with the unconventional cardiologist. The results showed that full-fat cheese was equivalent to low-fat cheese and to carbohydrates when it came to blood chemistries for cardiovascular disease, as well as to waist circumference (5). These markers included cholesterol, LDL “bad” cholesterol levels, fasting glucose levels and insulin. There were three groups in this study: those who consumed three ounces of full-fat cheese, low-fat cheese or refined bread and jam. The authors suggested that full-fat cheese may be part of a healthy diet. This means we can eat full-fat cheese, right? NOT SO FAST.

The study was faulty. The control arm was refined carbohydrates. And since both cheeses had similar results to the refined carbohydrates, the more appropriate conclusion is that full-fat and low-fat cheeses are no better for you than refined grains.

What about dairy fat?

In a meta-analysis (involving three studies — the Professional Follow-Up Study and the Nurses’ Health Studies 1 and 2), the results refute the claim that dairy fat is beneficial for preventing CVD (6). The results show that substituting a small portion of energy intake from dairy fat with polyunsaturated fats results in a 24 percent reduction in CVD risk. And doing the same with vegetable fats in replacement of dairy fat resulted in a 10 percent reduction in risk. Dairy fat was slightly better when compared to other animal fat.

This meta-analysis involved observational studies with a duration of at least 20 years and involving more than 200,000 men and women. There needs to be a large randomized controlled trial. But, I would not rush to eat cheese, whether it was the full-fat or low-fat variety. Nor would I drink bulletproof coffee anytime soon.

Saturated fat: not so good

In a recent meta-analysis (involving three studies run by the Harvard School of Public Health), replacing just 5 percent of saturated fats with both mono- and polyunsaturated fats resulted in a substantial reduction in the risk of mortality, 27 and 13 percent, respectively (7). This is a blow to the theory that saturated fats are not harmful to your health. 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. Again, this is an observational conglomeration of studies, using the same studies as with the dairy results above. This analysis suggests that the unconventional cardiologist’s approach is not the one you want to take.

The good news diet!

Here is the good news diet. In a recent randomized controlled trial (RCT), the gold standard of studies, results showed that high levels of polyphenols reduce the risk of cardiovascular disease (8). Polyphenols are from foods such as vegetables, fruits, berries especially and, yes, chocolate. The researchers divided the study population into two groups, high and low polyphenol intake. The biomarkers used for this study were endothelial (inner lining of the blood vessel) dependent and independent vasodilators. The more dilated the blood vessel, the lower the hypertension and the lower the CVD risk. These patients had hypertension, a risk factor for CVD. Those who consumed high levels of polyphenols had higher levels of nutrients such as carotenoids and vitamin C in their blood.

Is fish useful?

In a study, results show that eating a modest amount of fish decreases the risk of death from CVD by more than one-third (9). What is a modest amount? Consume fish once or twice a week. You want to focus on fish that are rich in omega 3s — docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). These are fatty fish with plenty of unsaturated fats, such as salmon. Thus, more of a Mediterranean-style diet, involving fruits and vegetables, as well as mono- and polyunsaturated fats in the forms of olive oil, nuts, avocado and fish may reduce the risk of CVD, while a more traditional American diet, with lots of pure saturated fats and refined carbohydrates may have the opposite effect. The reason we can’t say for sure that pure saturated fat should be avoided is that there has not been a large randomized controlled trial. However, many studies continually point in this direction.

References: (1) JAMA Intern Med. online Sept. 12, 2016. (2) Lancet. 2014;383(9932):1899-1911. (3) J Am Coll Cardiol. 2016;68(8):818-833. (4) NYTimes.com. (5) Am J Clin Nutr. 2016;104(4):973-981. (6) Am J Clin Nutr. Online Aug. 24, 2016. (7) JAMA Intern Med. 2016;176(8):1134-1145. (8) Heart. 2016;102(17):1371-1379. (9) JAMA. 2007;297(6):590.

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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Exercise and diet are key to losing weight.

By David Dunaief, M.D.

The more we seem to know about obesity as a chronic disease, classified this way first by the American Medical Association, the worse we in the medical community seem to have done to prevent and treat it and its complications. There are more obese people now than those who are overweight (1). Why would it be so difficult to treat a disease that has a simple solution, lose weight? How hard could that be, right?

If it were so simple to lose weight, we would not have an epidemic on our hands. We compete with internal and external forces, including forces from the food industry working to influence us every day. What is the problem with being obese? The issue with weight is not about vanity. The issue is that obesity creates medical complications and is second only to smoking in causing premature deaths (2). The research implies that weight loss in obese patients reduces the risk of death (3).

Life-threatening complications from obesity include multiple cancers, heart disease, stroke, diabetes, and nonalcoholic fatty liver disease. Is there something we can do about it? Simply, yes. Weight loss may have to do, at least in part, with the timing of when we eat. Also, exercise may help us increase lean muscle mass while decreasing body fat. Diet, of course, is important. A Mediterranean diet has only been shown to help with weight loss, not contribute to weight gain. There is too much doom and gloom about obesity. We need to focus on possible solutions first! Let’s look at the research.

Timing! Timing! Timing!

We have always been told not to eat late at night. Is there some truth to this, or is it an old wives’ tale? Well, it may be partially true; however, it may have more to do with how many hours we have access to food during a 24-hour period. Let me explain. In a recent study involving mice, results showed that those mice restricted to a 12-hour food consumption period in a 24-hour day were thinner than those allowed to eat anytime during the 24 hours. They may also have had reversal of metabolic disease, such as type 2 diabetes, in those mice who had pre-existing disease (4). Those that had access 24/7 became more obese and chronically ill. It did not matter which diet the mice ate.

Timing/access to food was the most important factor over the 38-week study. In fact, those that were initially given 24-hour access and then switched to the 12-hour limited access actually lost weight! Surprisingly, those that were limited to 12-hour food access could even cheat occasionally on the weekends, and it did not have a negative impact on their results. There were four diet groups — high fat and sucrose (a type of sugar), high fat, high fructose and typical diet. Of course, we are not mice. However, these are encouraging results.

Restricting eating to 12 consecutive hours during the day doesn’t seem like too much of a hardship. Now we need a randomized controlled trial in humans. In the meantime, I would suggest implementing these findings, even though we are not mice. There is no downside. In a previous study by the same research group, results showed that mice who had eight hours of access to food during a 24-hour period also showed considerably better results than those that had 24-hour access (5). Both mice groups were fed high-fat diets. The only difference was that one group was time restricted to eight hours of food exposure. The food-restricted mice saw an increase in prevention of metabolic parameters including diabetes, obesity and liver disease. The results also showed that restricting time to food decreased inflammation and improved energy expenditure. However, eight hours is more difficult to manage than 12 hours of access to food in a 24-hour cycle.

Mediterranean-type diet to the rescue

The Mediterranean diet has been valuable for a number of different chronic diseases, and obesity is no exception. In a meta-analysis (involving 16 randomized controlled trials, the gold standard of studies), the results showed that the Mediterranean-type diet was significantly better at helping patients lose weight when compared to a control diet (6). The longer the participants were on a Mediterranean-type diet, the greater the weight loss. Thus, this type of diet seems to get better with time. The meta-analysis involved over 3,000 participants. In none of the studies did any group on the Mediterranean diet gain weight.

Cancer is a weighty topic

We are always looking for cures for cancer. It is one of the more prevalent conglomerations of diseases. What might exacerbate cancer risk? If you guessed obesity, you would be right. Interestingly, it may have to do with duration of obesity that increases risk for cancer. This applies to multiple types of cancer. In a recent study, results showed that eight more cancers are associated with being overweight and obese, according to the International Agency for Research on Cancer (IARC), including mostly gastrointestinal cancers (liver, gallbladder, stomach and pancreas), as well as meningioma, thyroid, multiple myeloma and ovarian cancers (7). As we know, ovarian and pancreatic cancers tend to present with symptoms in the later stages and so are more lethal. This is added to the five cancers already known to be associated with obesity: esophageal, colorectal, uterine and post-menopausal breast cancers, plus renal cell carcinoma (kidney cancer).

The reasons for this association may have to do with the dysregulation of sex hormone breakdown and increased inflammation associated with body fat. According to the IARC, losing weight may be a way to reduce cancer risk, although studies that have shown this effect have been animal studies. However, this is pretty good motivation to lose weight. In another study, the results show the longer the duration of obesity, the greater the risk of developing cancer (8). According to the study results, for every 10 years of being overweight/obese, there was an additional 7 percent increase in the risk for several different cancers. The study involved over 70,000 postmenopausal women for a mean duration of 12.6 years.

Finally, the beverage industry’s black eye

A recent scientific review found that Coca-Cola and PepsiCo have spent millions and millions of dollars trying to influence medical organizations and public health institutions. They have put these groups in precarious situations by offering them money to help fund their organizations’ work, while asking them to back down on pressing issues such as a soda tax (9). The American Academy of Nutrition and Dietetics is, unfortunately, an example. However, the Institute of Medicine (IOM) has said that research shows soda has a strong association with the obesity epidemic (10). The moral of the story: We can and need to do a better job treating obese patients. One possible way to lose weight may be to restrict our access to food to the same 12-hour period each 24-hour cycle. Also, a Mediterranean diet has only been shown to cause weight loss, not weight gain.

References: (1) cdc.gov. (2) Lancet. online July 13, 2016. (3) Obes Rev. 2007;8(6):503-513. (4) Cell Metab. 2014;20(6): 991–1005. (5) Cell Metab. 2012;15(6):848-860. (6) Metab Syndr Relat Disord. 2011 Feb;9(1):1-12. (7) N Engl J Med. 2016;375:794-798. (8) PLoS Med. online August 16, 2016. (9) Am J Prev Med. online October 10, 2016. (10) hsph.harvard.edu/nutritionsource/sugary-drinks-fact-sheet.

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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Not all carbs are created equal. Photo by Heidi Sutton

By David Dunaief

It’s a persistent question: Should we minimize our carbohydrate consumption? Unfortunately, it depends on a number of factors including the type of carbohydrate and your family and personal history of chronic disease such as diabetes, cardiovascular disease, obesity, high triglycerides and hypertension. If this seems complicated and confusing to you, you are not alone. We have been bamboozled, railroaded or whatever term you like about carbohydrates for decades.

The body is like a chemistry set in that it turns many different types of carbohydrates into sugar. In other words, most of the sugar we consume is not what we add to food, but rather the food that our bodies turn into sugar. This is what’s so dangerous because it raises our blood sugar level.

The FDA has recently tried to quantify the amount of sugar we should consume on a daily basis (1). The agency recommends that we get no more than 50 grams of ADDED sugar a day. This seems like an easy task, for who would add 14.5 teaspoons of sugar to their food or drink in a day? Ah, but there is a catch: It includes processed foods such as refined carbohydrates and beverages. In fact, one can of soda may be enough to reach the upper limits of this recommendation.

We have been told for years that fats, especially saturated fats, were the enemy. Remember the food pyramid? The USDA had grains as its foundation for the longest time. Why would this be? Well, as it turns out, this is not a conspiracy theory but an actual scheme by the sugar industry to influence what we ate. They blamed fats as the cause for chronic diseases. However, they were very tricky in their approach, influencing scientists in the 1960s and 1970s with a small amount money, as was recently disclosed in a medical journal. We will discuss this in more detail.

Not all carbs are created equal

Carbohydrates come in many different forms. It depends on how much fiber they contain and whether they’re in liquid or solid form (2). Don’t focus on whether the carbohydrates are soluble or insoluble, complex or simple.

What is important is that some carbs don’t raise our blood sugar levels, while others have a much higher propensity to raise them. The carbs that don’t, or are less likely to, include fruits, nonstarchy vegetables, beans, legumes, pasta made from beans and tofu. With these, for the most part, you can eat a plentiful amount and may help prevent and even reverse chronic diseases such as diabetes, cardiovascular disease and obesity. However, carbs that raise our blood sugar are grains, especially refined grains, starchy vegetables like potatoes, fruit juice, sweets, bread, grain pasta, dried fruit, alcohol, soda, condiments and sauces. Let’s look at the evidence.

Sugar industry manipulation

You wouldn’t think we could be fooled by the sugar industry or distracted into thinking that saturated fats are what’s detrimental, not carbohydrates, and in their simplest form, sugars. This is just what the sugar industry did. A recent article in JAMA flushes this out (3).

The Sugar Research Foundation, the predecessor to the Sugar Association, paid three Harvard scientists to focus on fat and cholesterol as contributing factors to the rise in heart disease, not sugar. The resulting low-fat diet craze led to products loaded with sugar, like Snackwell cookies.

How much did they pay the researchers? A paltry $50,000 total in current monetary value. One of the scientists involved became the director of nutrition at the USDA. While the sugar industry and Harvard scientists in the 1960s may have conspired to downplay the dangers of sugar, strong evidence has now come to light that sugar, especially refined sugar, plays a role in heart disease and many other chronic diseases. However, this does not exonerate foods with high levels of saturated fat such as animal products.

We could never fall for this again, right? Well, that is what Coca-Cola was hoping to repeat recently by paying scientists millions of dollars to blame exercise, not diet, for the increase in heart disease, diabetes and obesity (4). This was recently revealed in a New York Times article entitled, “Coca-Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets.” The Global Energy Balance Network, a nonprofit advocacy group, was influenced by the funding from Coke. In fact, a 2013 peer-reviewed journal article argued similar ridiculous assertions (5). It was subsequently amended to note the funding by Coca-Cola. The difference is that scientists now have to disclose any paid industry associations when published in a peer-reviewed journal, unlike in the 1960s and 1970s.

Starchy vegetables — be leery!

It is not only refined grains that are a problem. Another is starchy vegetables, in this case potatoes. In a recent study, results showed that potatoes increased the risk of diabetes, while replacing them with whole grains may decrease this risk (6). Those who ate less than two to four servings of starchy vegetables per week had a 7 percent increased diabetes risk, and those who ate at least seven servings per week had a 33 percent increased risk. Those who consumed french fries had even higher risks for diabetes. This was a meta-analysis including data from three prestigious sources, the Health Professional Follow-up Study and The Nurses’ Health Study I and II, involving almost 200,000 men and women across the three studies with a minimum duration of 20 years.

Here is the corker: It did not matter what type of potato they were eating! Although I could not find data that delineated the different types of potato, this may imply sweet potato.

Whole fruit vs. nonstarchy veggies vs. starchy veggies

Many people who want to lose weight find the task to be downright daunting. The following may provide motivation. In a study, results showed that eating whole fruit helped people lose weight. Nonstarchy vegetables also had similar results; however, starchy vegetables caused people to put on the pounds (7). The fruits included berries, pears and apples. The vegetables with the most positive weight-loss impact were cauliflower and soy/tofu. Starchy vegetables included corn and potatoes. This was a meta-analysis involving three studies and over 130,000 men and women.

Clinical example — what a surprise!

In my practice, I had been encouraging patients to eat starchy vegetables that were high in a class of nutrients known as carotenoids. These starchy vegetables include sweet potato, acorn squash, butternut squash, spaghetti squash, pumpkin and corn. Well, it turns out that a number of my patients indeed had higher nutrient levels in their blood, but unfortunately had no decrease in the inflammatory marker, C-reactive protein (CRP), that usually accompanies this effect. Even worse, their triglycerides, insulin levels and HbA1C, a measure of three-month sugars, were actually elevated and they could not lose weight.

The moral of the story is that we don’t have to be on a low-carb diet. Instead, we should focus on consuming carbohydrates that may prevent and reverse disease, such as fruits, nonstarchy vegetables and beans, while trying to minimize those that would potentially have the opposite effect, including starchy vegetables, disappointingly. The response to carbohydrates tends to depend on individuality when it comes to whole grains and starchy vegetables, though those with diabetes, heart disease, obesity and hyperinsulinemia would be advised to minimize their intake. Of course, all of us should minimize our intake of refined grains, sugars and processed foods.

References: (1) FDA.gov. (2) Uptodate.com. (3) JAMA Intern Med. online Sept. 12, 2016. (4) NYTimes.com. (5) PLoS One. 2013 Oct 9;8(10):e76632. (6) Diabetes Care. 2016;39(3):376-384. (7) PLoS Med. 2015;12(9):e1001878.

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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