It seems like everyone has heard of hypothyroidism. But do we really know what it is and why it is important? The thyroid is a butterfly-shaped organ responsible for maintaining our metabolism. It sits at the base of the neck, just below the laryngeal prominence, or Adam’s apple. The prefix “hypo,” derived from Greek, means “under” (1). Therefore, hypothyroidism indicates an underactive thyroid and results in slowing of the metabolism. Many people get hypo- and hyperthyroidism confused, but they are complete opposites.

Blood tests determine if a person has hypothyroidism. Items that are tested include thyroid stimulating hormone (TSH), which is usually increased, thyroxine (free T4) and triiodothyronine (free T3 or T3 uptake), which may both be suppressed (2).

There are two types of primary hypothyroidism: subclinical and overt. In the overt (more obvious) type, classic symptoms include weight gain, fatigue, thinning hair, cold intolerance, dry skin and depression, as well as the changes in all three thyroid hormones on blood tests mentioned above. In the subclinical, there may be less obvious or vague symptoms and only changes in the TSH. The subclinical can progress to the overt stage rapidly in some cases (3).  Subclinical is substantially more common than overt; its prevalence may be as high as 10 percent of the U.S. population (4).

What are potential causes or risk factors for hypothyroidism? There are numerous factors, such as medications, including lithium; autoimmune diseases, whether personal or in the family history; pregnancy, though it tends to be transient; and treatments for hyperthyroidism (overactive thyroid), including surgery and radiation.

The most common type of hypothyroidism is Hashimoto’s thyroiditis (5). This is where antibodies attack thyroid gland tissues. Several blood tests are useful to determine if a patient has Hashimoto’s: thyroid peroxidase (TPO) antibodies and antithyroglobulin antibodies.

Myths versus realities

I would like to separate the myths from the realities with hypothyroidism. Does treating hypothyroidism help with weight loss? Not necessarily. Is soy potentially bad for the thyroid? Yes. Does coffee affect thyroid medication? Maybe. And finally, do vegetables, specifically cruciferous vegetables, negatively impact the thyroid? Probably not. Let’s look at the evidence.

Treatments: medications and supplements

When it comes to hypothyroidism, there are two main medications: levothyroxine and Armour Thyroid. The difference is that Armour Thyroid converts T4 into T3, while levothyroxine does not. Therefore, one medication may be more appropriate than the other, depending on the circumstance. However, T3 can be given with levothyroxine, which is similar to using Armour Thyroid.

What about supplements? A recent study tested 10 different thyroid support supplements; the results were downright disappointing, if not a bit scary (6). Of the supplements tested, 90 percent contained actual medication, some to levels higher than what are found in prescription medications. This means that the supplements could cause toxic effects on the thyroid, called thyrotoxicosis. Supplements are not FDA-regulated, therefore, they are not held to the same standards as medications. There is a narrow therapeutic window when it comes to the appropriate medication dosage for treating hypothyroidism, and it is sensitive. Therefore, if you are going to consider using supplements, check with your doctor and tread very lightly.

Soy impact

What role does soy play with the thyroid? In a randomized controlled trial, the gold standard of studies, the treatment group that received higher amounts of soy supplementation had a threefold greater risk of conversion from subclinical hypothyroidism to overt hypothyroidism than those who received considerably less supplementation (7). Thus, it seems that in this small yet well-designed study, soy has a negative impact on the thyroid. Therefore, those with hypothyroidism may want to minimize or avoid soy. Interestingly, those who received more soy supplementation did see improvements in blood pressure and inflammation and a reduction in insulin resistance but, ultimately, a negative impact on the thyroid.

The reason that soy may have this negative impact was illustrated in a study involving rat thyrocytes (thyroid cells) (8). Researchers found that soy isoflavones, especially genistein, which are usually beneficial, may contribute to autoimmune thyroid disease, such as Hashimoto’s thyroiditis. They also found that soy may inhibit the absorption of iodide in the thyroid.

Weight loss

Since being overweight and obese is a growing epidemic, wouldn’t it be nice if the silver lining of hypothyroidism is that, with medication to treat the disease, we were guaranteed to lose weight? In a recent retrospective (looking in the past) study, results showed that only about half of those treated with medication for hypothyroidism lost weight (9). This has to be disappointing to patients. However, this was a small study, and we need a large randomized controlled trial to test it further.

WARNING: The FDA has a black box warning on thyroid medications — they should never be used as weight loss drugs (10). They could put a patient in a hyperthyroid state or worse, having potentially catastrophic results.

Coffee

I am not allowed to take away my wife’s coffee; she draws the line here with lifestyle modifications. So I don’t even attempt to with my patients, since coffee may have some beneficial effects. But when it comes to hypothyroidism, taking levothyroxine and coffee together may decrease the absorption of levothyroxine significantly, according to one study (11). It did not seem to matter whether they were taken together or an hour apart. This was a very small study involving only eight patients. Still, I recommend avoiding coffee for several hours after taking the medication. This should be okay, since the medication must be taken on an empty stomach.

Vegetables

There is a theory that vegetables, specifically cruciferous ones such as cauliflower, cabbage and broccoli, may exacerbate hypothyroidism. In one animal study, results suggested that very high intake of these vegetables reduces thyroid functioning (12). This study was done over 30 years ago, and it has not been replicated.

Importantly, this may not be the case in humans. In the recently published Adventist Health Study-2, results showed that those who had a vegan-based diet were less likely to develop hypothyroidism than those who ate an omnivore diet (13). And those who added lactose and eggs to the vegan diet also had a small increased risk of developing hypothyroidism. However, this trial did not focus on raw cruciferous vegetables, where additional study is much needed.

There are two take-home points if you have hypothyroid issues: Try to avoid soy products, and don’t think supplements that claim to be thyroid support and good for you or harmless because they are over the counter and “natural.” In my clinical experience, an anti-inflammatory, vegetable-rich diet helps improve quality of life issues, especially fatigue and weight gain, for those with Hashimoto’s thyroiditis.

References:

(1) dictionary.com. (2) nlm.nih.gov. (3) Endocr Pract. 2005;11:115-119. (4) Arch Intern Med. 2000;160:526-534. (5) mayoclinic.org. (6) Thyroid. 2013;23:1233-1237. (7) J Clin Endocrinol Metab. 2011 May;96:1442-1449. (8) Exp Biol Med (Maywood). 2013;238:623-630. (9) American Thyroid Association. 2013;Abstract 185. (10) FDA.gov. (11) Thyroid. 2008;18:293-301. (12) Crit Rev Food Sci Nutr. 1983;18:123-201. (13) Nutrients. 2013 Nov. 20;5:4642-4652.

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.

When we think about aging, chronological age comes to mind first. For many, the perceived ideal age is around 25. My wife refers to her birthday every year as the “X anniversary of her 25th birthday.” After 40, we are on the downslide, right? Not so fast. Age may be more than the ticking of the clock; it is less about time and more about telomere length, brain volume and heart age, or what we call “biological age.” We may be too obsessed with chronological age, when we should be focused on biological age and how we can alter it for the better.

According to a recent study, we need to lift weights twice a week to see a potential beneficial effect on the brain. I will discuss this further.

In another study, results demonstrate that aging may be based primarily on environment and secondarily on your genes, 50 percent and 25 percent, respectively (1). This study used identical twins and fraternal twins in Scandinavian countries. Frankly, I did not realize just how much of an impact environment has on aging. Gene influence does increase after the age of 60, though. Since much of aging is based on environment, it means that there are risk factors that can accelerate the aging process and other factors that may slow it down.

What is an aging accelerator?

Sedentary activity, an oxymoronic term, can lead to weight gain and chronic diseases, so it’s no surprise that this can also lead to a shorter life span. In a recent study, those who spent more sedentary leisure time on screen-based activities were more likely to have reduced telomere length (2). Telomeres are repetitive sequences of DNA found at the ends of our DNA. They are similar to caps on the ends of shoelaces; they prevent our DNA from fraying. When telomere length is reduced, it can result in premature aging. In this study, for every sedentary hour, there was a 7 percent chance of significant reduction in leukocyte (white blood cell) telomere length. According to the authors, shortened telomere length has been associated with increase morbidity (disease) and mortality.

What is a consequence of        premature biological aging?

One of the most feared diseases as we age is dementia, specifically Alzheimer’s dementia. In a study, a shortened telomere length was associated with a greater than one-third increased risk of Alzheimer’s disease (3). This study suggests that shortened telomere length is not just a biomarker; it may be involved in the actual cause of Alzheimer’s. The authors warn that there is no clear method to measure telomere length and to be wary of any company that offers this service.

What is the significance of      heart age?

According to a CDC study, heart age may actually matter more than chronological age (4). Heart age is defined here as the cardiovascular risk profile that determines one’s vascular (arteries and veins) health. Researchers used the Framingham Risk Score calculator to evaluate biological age based on heart health. The score predicts the 10-year risk of developing cardiovascular disease. A higher score results in increased risk and accelerated biological age, while a lower score results in a lower risk and lower biological age than actual age. This scoring calculator uses age, BMI, systolic (top number) blood pressure, sex and whether you are treated with drugs for high blood pressure and diabetes. The calculator is here: https://www.cdc.gov/vitalsigns/cardiovasculardisease/heartage.html.

Systolic blood pressure seems to have the most effect, with a systolic blood pressure of 125 mmHg resulting in a neutral effect. Only about 30 percent of patients have a heart age equal or below their actual age, with the mean biological age 7.8 years above actual age for men and 5.4 years above for women. Unfortunately, this calculator does not take into account lifestyle modifications, such as diet and exercise.

So what are the effects of          diet and exercise?

The explorer Ponce de Leon spent much of his life searching for the fountain of youth. We may have found a modified fountain in the form of cardiovascular exercise, weight lifting and the Mediterranean-type diet. These are factors that may make your biological age significantly lower than your actual age.

Don’t resist resistance training

We are not talking about lifting heavy weights, but rather the frequency of light weight lifting. In a recent study, lifting weights two times a week had a significantly better effect on the number of white matter lesions in the brain and on gait speed than lifting one time a week or less (5). White matter helps the brain make connections, carrying information from one part of the brain to another. Lesions may impede this process. This was a well-designed, though small, one-year, randomized controlled trial, the gold standard of studies, with 155 female participants. Patients were divided into three groups: light upper and lower body weight lifting twice a week, the same regimen once a week, or a stretching and balance regimen.

How can exercise elongate cell life?

In another study, exercise appeared to prevent or reduce the risk of shortened telomeres. Telomeres are important for protecting the DNA and, ultimately, the cell (6). There were four different categories of exercises surveyed. If respondents said yes to each category, there was an exponentially greater chance that they would not have very short telomeres. The categories included walking, running, walking/riding a bike to work or school, and weight lifting. If a participant was involved in one category in the previous month, there was a 3 percent reduced risk of shorter telomeres, whereas participants who were involved in all four categories had a 59 percent reduced risk of having very short telomeres. This greatest impact was seen in adults between ages 40 and 65.

How about diet?

In the WHICAP study, better compliance with a Mediterranean-type diet slowed the process of brain atrophy (7). According to the researchers, this was equivalent to a five-year reduction in biological age. There were nine components to the diet. The most interesting part was that increased fish and decreased meat consumption was most beneficial.

What does increased fish intake mean? It is less than you would think — three to five ounces a week total. The components in fish that may contribute to this positive effect are omega 3 fatty acids, B vitamins, vitamin C and astaxanthin, a carotenoid. This study involved 674 elderly adults who lived in New York City. The researchers measured brain volume by MRI. Though it was not studied, the authors note that brain atrophy is associated with cognitive decline. So avoiding or slowing brain atrophy should be an imperative.

The moral of the story for aging: Try not to obsess over something that you can’t change, your chronological age. Instead, focus your energies on biological age, which is more pliable and may respond to lifestyle modifications.

References:

(1) Hum Genet. 2006;119(3):312. (2) Mayo Clin Proc. 2015;90(6):786-790. (3) JAMA Neurol. 2015;72:1202-1203. (4) Morb Mortal Wkly Rep. online Sept. 1, 2015. (5) J Am Geriatr Soc. 2015;63(10):2052-2060. (6) Med Sci Sports Exerc. 2015;47(11):2347-2352. (7) Neurology 2015;85:1-8.

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.

We talk a good story about prevention, but most of the time, we in the medical community are guilty of confusing primary prevention with early detection. Breast cancer is no exception.

If you’re a woman and thought that there was not enough intrigue during a doctor’s appointment, the new recommendations from the American Cancer Society (ACS) and the results from the recent ductal carcinoma in situ (DCIS) study should help spice up the conversation with your physician.

For the first time since 2003, the ACS has changed its recommendations for the use of mammography in the early detection of cancer. The guidelines have become less aggressive. We will review this in greater detail.

What about DCIS? This is where atypical cells that look like potential cancer cells that may metastasize can be picked up on mammography. DCIS is known as stage 0 cancer. DCIS is found specifically in the mammary glands (milk ducts). The in situ portion of the phrase means “in place.” The current treatment regimen almost certainly involves surgery — a lumpectomy, mastectomy (complete removal of the breast), or even double mastectomy. DCIS has the potential to progress to invasive cancer, or it may be cancer in its own right.

However, it may not. This is where the quandary begins. It may just be another potential risk factor for those with average risk. We are not talking about those with high risk, either personal or family history. This is a different category.

DCIS used to make up 3 percent of breast cancer diagnoses. But now, it has increased to approximately a quarter of breast cancer diagnoses in the United States (1), in large part due to the use of mammography. The expected number of women diagnosed with DCIS in 2015 is 60,000 (2).

And then there is diet, which may help with the primary, or “true,” breast cancer prevention. Let’s look at the research.

How have the ACS guidelines changed for mammography?

Ironically, during breast cancer awareness month, the ACS, a well-respected organization, loosened the guidelines for average-risk patients (3). Changes include the age and frequency of mammography, based on data from randomized controlled trials, observational trials and modeling studies done since 2003. ACS increased the recommended mammography age from 40 to 45 years old. Then recommending patients be screened by mammography annually until age 54. After 54, the exam should be biennial (every other year), as long as the predicted reasonably healthy life span is at least 10 years.

However, women may use their own prerogative to obtain mammograms annually between 40 and 44 years old and after 54. The ACS no longer recommends clinical (in-office) breast exams in average-risk women. It may not seem like a large difference, but after having talked to some gynecologists, they are more comfortable with starting patient screening at age 45.

The reasons for these changes include the recognition that mammography is less than perfect and may result in recall, especially in younger women, and a potential for false positives, which can lead to invasive biopsies. Also, the clinical breast exams data is very low quality (4).

Unfortunately, there is no uniformity among the recommendations. The ACS recommendations are not as radical as the United States Preventive Services Task Force (USPSTF), though they are getting closer. In 2009, USPSTF recommended women undergo mammography starting at age 50 and every other year until 75 (5). Like ACS, USPSTF doesn’t recommend clinical breast exams.

Stage 0 breast cancer — DCIS

We used to think there was a linear relationship in cancer, where early-stage cells would eventually become malignant. However, this may not always be the case. In fact, we may be overtreating DCIS, this early form of breast cancer. In the SEER study, results showed that, at the 20-year mark, mortality rate was similar, 3.3 percent, regardless of surgical treatment with either lumpectomy with or without radiation or a mastectomy (6). This percent is similar to ACS’s estimated average risk of women in general dying from breast cancer.

However, the rate of mortality was greater in those who were under 35 years old, compared to older women and for those who were black, with a 2.5-fold increased risk for both groups. Many times, those under ages 35 to 40 with DCIS are symptomatic, presenting with a significant mass and blood discharge from the nipple. Certain characteristics increase risk of DCIS mortality, such as estrogen receptor status, the size of the mass, as well as grade of DCIS. If the DCIS developed into invasive breast cancer, then the risk of death went up 13 to 18 times.

The problem is, it is not clear who will develop DCIS that will result in mortality in its own right or develop invasive breast cancer. Recurrence of DCIS did not have an increase in mortality. There were approximately 100,000 women in this large observational study. We need randomized controlled trials as follow-up to this data before more definitive statements can be made. Interestingly, this is eerily similar to early-stage prostate cancer, where the younger male population and blacks have higher risks of advanced disease and death.

The incidence of breast cancer mortalities should have declined as more and more DCIS cases were identified. Unfortunately, there has been no significant change in mortality from breast cancer (7). Aggressive treatments with radiation after lumpectomy did not result in any more favorable results than without radiation. Some gynecologists have suggested that, if you receive a DCIS diagnosis, a second pathology consult might be in order to confirm that it’s DCIS.

Lifestyle to the rescue

In the PREDIMED trial, results show that with the Mediterranean-type diet that includes supplemental olive oil, the risk of malignant breast cancer was reduced by a significant 68 percent, compared to the control arm (8). The control arm was based on a low-fat diet. The strengths of this trial were that it was the first randomized controlled trial with diet and breast cancer, as well as having 4,152 participants and a solid duration of 4.8 years.

Unfortunately, there were weaknesses; breast cancer was a secondary end point, so not everyone received a screening mammography at baseline, and there was a low overall incidence of breast cancer. Still, this is an exciting trial that needs to be repeated. The diet may have been advantageous because of its antioxidant properties. There were no adverse reactions to the Mediterranean diet; in fact, this trial was stopped early because of positive cardiovascular results, the primary end point.

It could be summed this way: If you want simple, true prevention, then think diet! If you have DCIS, you will likely have a stimulating conversation with your doctor about options. There is even a breast surgeon at UCSF, Laura J. Esserman, M.D., who is willing to put average-risk DCIS patients on active surveillance instead of surgery, though she is in the minority. And for all of you who hate the pain of having your breasts crushed during mammography, you can thank the ACS for the guideline changes.

References:

(1) www.cancer.org/acs. (2) CA Cancer J Clin. 2015;65(1):5. (3) JAMA. 2015;314(15):1599-1614. (4) JAMA. 2015;314(15):1569-1571. (5) uspreventiveservicestaskforce.org. (6) JAMA Oncol. 2015;1(7):888-896. (7) JAMA Oncol. 2015;1(7):881-883. (8) JAMA Intern Med. online Sept. 14, 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.

Soda has a lot of sugar, with 39 grams per 12-ounce can. Not surprising, soda is associated with increased risk of diabetes. However, the drink with the lowest amount of sugar is wine, red or white. Even more surprising, it may have benefits in reducing complications associated with diabetes. Wine has about 1.2 grams of sugar in five ounces. I know what you’re thinking: these different drinks are based on different quantities; however, per ounce, soda has the most and wine has the least.

Why is this important? Well, it wouldn’t be if diabetes were going the way of the dodo bird. Instead, the prevalence of diabetes has continued to climb over three decades in the United States at an alarmingly rapid rate to its current level of 12 to 14 percent (1). The even scarier news is that more than one-third don’t know they have diabetes. The number of patients with prediabetes (HbA1C of 5.7-6.4 percent) is greater than one in three in this country.

So where do we stand? Unfortunately, the United States Preventive Services Task Force (USPSTF) and the American Diabetes Association (ADA) can’t agree on screening guidelines. The USPSTF recently recommended that asymptomatic patients not be screened for diabetes since the evidence is inconclusive and screening may not improve mortality. ADA guidelines suggest testing those who are overweight and who have one or more risk factors for diabetes and all of those who are over 45 (2, 3).

It turns out that cardiovascular risk and severity may not be equal between the sexes. In two recent trials, women had greater risk than men. In one study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (4). This was a retrospective (backward-looking) study. The same result was found in a second study (5). In this meta-analysis (a group of 19 studies), there was a 38 percent greater increased risk of cardiovascular events in women than men. However, these studies were presented as posters, not yet fully published data.

What may reduce risks of disease and/or complications?

Fortunately, we are not without options. Several factors may help. These include timing of blood pressure medications, lifestyle modifications (diet and exercise) and wine.

Diet trumps popular drug
for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a recent head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (7). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. While these are impressive results that speak to the use of lifestyle modification and to metformin, this is not the optimal diabetes diet.

Wine is beneficial, really?

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a recent randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (6). Patients were randomized into three groups, all receiving a drink with dinner nightly; one group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed on how to follow a Mediterranean-type diet. Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Drugs — not diabetes drugs — show good results

I wrote that taking blood pressure medications at night may control blood pressure better than only taking these medications in the morning. Well, it turns out this recent study also shows that taking blood pressure medications has another benefit, lowering the risk of diabetes (8). There was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning. It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants. The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a nonideal diet in comparison to medication had better results, though medication such as metformin could be used in high-risk patients that were having trouble following the diet. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) JAMA 2015;314(10):1021-1029. (2) uspreventiveservicestaskforce.org. (3) Diabetes Care 2015;38(Suppl. 1): S1–S94. (4) EASD 2015; Poster #265. (5) EASD 2015; Poster #269. (6) Ann Intern Med. 2015;163(8):569-579. (7) Lancet Diabetes Endocrinol. Online September 11, 2015. (8) Diabetologia. Online September 23, 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.

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 breast cancer incidence in the United States is 230,000 cases, with approximately 40,000 patients, or 17 percent, 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 a recent 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 its “Play 60” campaign.

Soy intake

Contrary to popular belief, soy may be beneficial in reducing breast cancer risk. In a recent 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 versus Mediterranean diets

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) CA Cancer J Clin. 2013;63:11-30. (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, go to the website www.medicalcompassmd.com or consult your personal physician.

We in the medical community, of course, know what the optimal blood pressure levels should be with medication. Or do we? How can that be, when we have been treating hypertension (high blood pressure) for years? This is very important to know, since according to NHANES data, approximately 76 million adults over 20 in the United States have hypertension (1). Target blood pressure may depend on age and comorbidities, such as diabetes. We know that blood pressure should be less than 150/90 mmHg for everyone. From there, the data gets a bit fuzzy.

If optimal levels are unclear, then prevention of hypertension should be crucial; if you don’t have it, you don’t have to think about this conundrum. It turns out that exercise reduces the risk of this disease. No surprise there. But the level of physical activity needed to reduce the risk is intriguing. The intensity and the duration are a lot less than we had thought, though the frequency may be higher.

Another question frequently asked is, does it matter what time you take the medication? The answer may be yes. Not only for controlling blood pressure but also for preventing diabetes.

Finally, is it ever too early to start controlling high blood pressure in those who are 18 and older? No, according to a study with significant durability. Let’s look at the research.

Lower is better — maybe

A recent study has suggested that lower is better when it comes to treating hypertension with medication. In the Systolic Blood Pressure Intervention Trial (SPRINT), results showed that lower was better when it came to controlling blood pressure (2). What levels did the research suggest? It was a systolic (top number) blood pressure of less than 120 mmHg, which is very aggressive.

To achieve this, at least three blood pressure medications were used in each patient. Compared to the standard less than 140 mmHg systolic blood pressure target, there was a significant, almost 25 percent, reduction in all-cause mortality and a 30 percent reduction in cardiovascular events. There were over 9,000 patients in this randomized controlled trial, the gold standard of studies. The patients had hypertension plus one additional comorbidity (except diabetes and prior stroke) and were over age 50. Interestingly, a quarter of patients were at least 75 years of age, making this one of the few studies with a substantial number of older hypertension patients. These results are impressive, if they hold up to analysis.

What are the caveats to this study? And there are caveats. For one thing, the study was halted and the data were released early because of these positive results, but it has yet to be published or fully analyzed. The effects on the kidneys and potential slowing of cognitive decline are being evaluated. My specific concern is that patients who want to embrace lifestyle modifications that help treat hypertension will be at higher risk of becoming hypotensive (low blood pressure) if they start out below a systolic blood pressure (SBP) of 120 mmHg on at least three medications. It is most wise to wait until the data have been published in a peer-reviewed medical journal before attempting this target blood pressure.

What about the current guidelines?

The guidelines as of 2013/2014 from both the JNC 8 and the ASH/ISH may differ slightly, but they recommend loosening the target systolic blood pressure to less than 150 mmHg for patients over 60 and 80 years of age, and 140 mmHg for most everyone else (3). Isn’t medicine wonderful? It always has the potential to change with new study data.

What about younger populations with hypertension?

Even though we talk about high blood pressure affecting younger adults, we don’t see a lot of studies focused on this topic. In the CARDIA study, results show that the cumulative effects of high blood pressure from young adult age to middle age had significant negative effects on the left ventricular function (a chamber of the heart involved in pumping blood to the body and brain), increasing the risk of heart failure (4). Interestingly a high diastolic (lower number) blood pressure had the most detrimental effect on left ventricular function, though a high systolic number also had significant negative impact. This was a prospective (forward-looking) study with a very solid duration of 25 years. The patients were 18 to 30 years old at the start of the trial and completed it at a mean age of 50. The moral of the story: treat patients who have high blood pressure, regardless of age.

Don’t forget about the bottom number — diastolic blood pressure

There was a fear that lowering diastolic blood pressure (DBP) too far would have ill effects. This is called the J-curve effect, where lowering with medication is good, but too low could have negative effects. However, in a study involving 4,000 patients, there was no increased risk of dying when the diastolic blood pressure was decreased to less than 80 mmHg (5). There were two problems with this study. One, the J-curve could happen at levels below 70 mmHg, but this was not tested. And two, patients may or may not have had cardiac events without dying, which was also not an end point.

However, another study, based on the Framingham Heart Study and the offspring of that study, showed that those with isolated systolic hypertension (>140 mmHg) and DBP <70 mmHg had increased risk of recurrent cardiovascular disease events regardless of whether they were on medication or not, compared to those who had DBP between 70 and 89 mmHg (6). In other words, there was a J-curve effect when the DBP was <70 in those with systolic hypertension.

Physical activity

Exercise is important for blood pressure control. But how much? In a study, results showed that walking for 10 minutes three times a day was more effective than exercising 30 minutes once per day in those with prehypertension (SBP 120-139 mmHg) (7). In another study, standing, walking or cycling at a snail’s pace (1.0 mph) every hour for 10 to 20 minutes was significantly more effective at controlling blood pressure than sitting continuously for eight hours (8).

Timing is everything!

In a prospective study, results showed that those who took their blood pressure medications at night had a 57 percent decreased risk of developing diabetes as well as a better controlled blood pressure during the night (9). This was a randomized controlled trial involving 2,012 patients for almost six years. The medications used were mainly from the ACE inhibitor, ARB and beta-blocker classes.

We know controlling blood pressure is important, but to what levels with medication remains to be determined. The potential J-curve with diastolic blood pressure may add to this complication. Remember, high blood pressure can be present at any adult age. But taking medication at night seems to be beneficial. Treating with lifestyle modifications is important to avoid medications’ dilemma.

References:

(1) Natl Health Stat Report. 2011. (2) nih.gov. (3) JAMA. 2014;311(5):507-520; J Clin Hypertens (Greenwich). 2014;16(1):14-26. (4) J Am Coll Cardiol. 2015; 65:2679-2687. (5) ESH 2015 Abstract LB02.06. (6) Hypertension. 2015;65:299-305. (7) Med Sci Sports Exerc. 2012;44(12):2270-2276. (8) Med Sci Sports Exerc. Online Aug. 17, 2015. (9) Diabetologia online Sept. 23, 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.

There has been some discussion in the medical community about whether the annual physical exam may have outlived its usefulness. Is it a reflex, or does it have an important role? The answer, I think, depends on how you perceive and utilize this yearly ritual.

If annual medical exams mean lots of expensive diagnostic tests and invasive procedures, it may be time to put it out to pasture. However, if it fosters a physician-patient relationship and allows for a partnership in prevention and treatment of diseases, then this alone may be a good reason to keep it. Doctors and patients alike complain there is not enough time spent getting to know or understand each other’s approaches. Eliminating the annual physical would only worsen the situation.

So what are the pros and cons of this time-tested ritual?

Downsides

One of the downsides may be that the yearly ritual does not save lives. According to a Cochrane meta-analysis (a group of 16 studies), an annual physical exam had no benefit related to mortality risk and morbidity (disease) risk (1). The report went on to say that it did not have an effect on overall mortality, nor on cancer survival and/or cardiovascular mortality. Nine trials were utilized for mortality data. The study weakness could be that the trials included were old and may not be applicable to more modern approaches. The authors also suggested that primary care physicians may already be treating patients at high risk for diseases.

PSAs

Another potential negative to annual exams is that certain diagnostics, such as prostate-specific antigen screenings to test for prostate cancer, could be harmful. In a recently presented abstract (2), the results of a meta-analysis show that routine screening for prostate cancer in the general, symptom-free male population may have more detrimental effects than benefits — a high PSA may lead to unnecessary invasive procedures, such as biopsies and prostatectomies (removal of the prostate). Side effects could be impotence and infection and could result in hospitalization. The author acknowledged that there have been two large studies on PSAs, one touting the benefits and the other showing increased harm. This latest assessment may be the tiebreaker. Some urologists may disagree with these newest findings.

Upsides

What are the upsides of an annual medical checkup? Not all diseases show symptoms, especially in the earlier stages. Examples include hypertension (high blood pressure) and chronic kidney disease. This is also an opportunity to discuss mental health — stress levels, depression and anxiety. And, of course, there is the importance of lifestyle discussions, including weight, exercise and diet.

Chronic kidney disease

Though chronic kidney disease (CKD) does not have an awareness month, it is no less significant than breast cancer or prostate cancer, causing upward of 90,000 deaths per year. According to the Centers for Disease Control and Prevention, one in five patients with high blood pressure has chronic kidney disease (3). Early to moderate stages of the disease may go undetected, since the only way to detect it when it has no symptoms is through blood tests and urinalysis.

If there is protein in the urine and/or reduction in the estimated glomerular filtration rate and creatinine in the blood, this may be a sign of CKD. Detecting CKD early may be the key to halting its progress and preventing end-stage kidney disease resulting in dialysis. Without the annual medical exam, we may miss the opportunity to detect this disease in its early stages.

High blood pressure

High blood pressure is known as the “silent killer” because there are frequently no symptoms until it is too late. According to a study, high blood pressure may be responsible for almost half of all heart attacks and a quarter of premature deaths in the United States (4).

To reduce the risk of this silent killer, lifestyle modifications are in order. In a meta-analysis, involving 54 small, randomized controlled trials, aerobic exercise had significant benefits in reducing blood pressure. This was true of patients with elevated and with normal blood pressure, as well as those who were obese and those of normal weight (5). Very few lifestyle changes alter blood pressure in “healthy” patients, but ones that do may reduce risk of ever developing the disease. In this trial, the systolic blood pressure (top number) was significantly reduced by a mean of 3.4 mmHg.

Body mass index

The first step toward obesity prevention and treatment is an awareness of the problem. According to a report by the Institute of Medicine advocating for an obesity task force, physicians should regularly monitor patients’ body mass index (6). This may give patients a sense of urgency to lose weight. In my practice, I also assess body composition, which includes fat percent and fat mass. Though someone may not be obese, their fat mass may be higher than normal. With BMI, those who are less than 30 kg/m2 are considered nonobese, and those who are less than 25 kg/m2 are considered to be in the normal range.

Depression

A physical exam and labs are important, but, ultimately, you should not treat the numbers. Instead, physicians are trained to treat the patient. One of the most effective ways to get to know a patient and recommend effective prevention and treatment is with a thorough discussion of history. This is the art of medicine, and it involves the intangibles that may not show up in numbers, including mental health issues.

A recent abstract showed it is not what patients say, but how they say it that may be most important. Short essays were used to help determine whether patients were sad or actually mildly depressed (7). Those who were mildly depressed used significantly more verbs in the past tense than the present (100 percent versus 2.6 percent) and used less complex sentences, compared to the healthy control patients.

Ultimately, I think the success of an annual medical checkup has to do with the approach. If there is a strong focus on a thorough history, rather than a predominance of diagnostic testing leading to invasive procedures, there is very little downside. The yearly medical exam is an opportunity to discuss preventive measures, including lifestyle changes, whether the patients are healthy or have disorders that may be prevented from worsening.

References:

(1) Cochrane Database Syst Rev. 2012 Oct. 17. (2) European Cancer Conference 2013; Abstract 1481. (3) CDC.gov. (4) BMJ. 2001;322:977-980. (5) Ann Intern Med. 2002;136:493-503. (6) Evaluating Obesity Prevention Efforts, National Academies Press, online Aug. 2. (7) 26th European College of Neuropsychopharmacology Congress; Abstract P.2.b.060.

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.

Osteoarthritis is widespread. The more common joints affected are the knees, hips and hands. There are three types of treatment for this disease: surgery, involving joint replacements of the hips or knees; medications; and nonpharmacologic approaches. The most commonly used first-line medications are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, medications mostly treat the symptoms of pain and inflammation.

However, the primary objectives in treating osteoarthritis should also include improving quality of life, slowing progression of the disease process and reducing its disabling effects (1).

Dairy and milk

When we think of dairy, specifically milk, there are two distinct camps: one believes in the benefits, and the other thinks it may contribute to disease. In this case they both may be at least partly correct. In the Osteoarthritis Initiative study, an observational study of over 2,100 patients, results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis (2).

The researchers looked specifically at joint space narrowing that occurs in those with affected knee joints. Radiographic imaging changes were used at baseline and then to follow the patients for up to 12 to 48 months for changes. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space.

Was it a dose-dependent response? Not necessarily. Specifically, those who drank less than three glasses/week and those who drank four to six glasses/week both saw slower progression of joint space narrowing of 0.09 mm. Seven to 10 glasses/week resulted in a 0.12 mm preservation. However, those who drank more than 10 glasses/week saw less beneficial effect, 0.06 mm preservation compared to those who did not drink milk. Interestingly, there was no benefit seen in men or with the consumption of cheese or yogurt.

However, there are significant flaws with this study. First, patients were only asked about their dietary intake of milk at baseline; therefore their consumption could have changed during the study. Second, there was a recall bias; patients were asked to recall their weekly milk consumption for the previous 12 months before the study began. I don’t know about you, but I can’t recall my intake of specific foods for the last week, let alone for the past year. Third, there could have been confounding factors, such as orange juice consumption.

Oddly, this was not a dose-response curve, since the most milk consumption had less beneficial effect than lower amounts. Also, why were these effects only seen in women? Finally, researchers could not explain why low-fat or nonfat milk had this potential benefit, but cheese was detrimental and yogurt did not show benefit. We are left with more questions than answers.

Would I recommend consuming low-fat or nonfat milk? Not necessarily, but I may not dissuade osteoarthritis patients from drinking it. There are very few approaches that slow the progression of joint space narrowing.

Vitamin D

Over the last five years or so, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a recent randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief nor any disease-modifying effects (3). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

Glucosamine

There is raging debate about whether glucosamine is an effective treatment for osteoarthritis. In the latest installment, there was an RCT, the results of which showed that glucosamine hydrochloride was not effective in treating osteoarthritis (4). In the trial, 201 patients with either mild or moderate knee pain drank diet lemonade with or without 1500 mg of glucosamine hydrochloride.

There was no difference in cartilage changes in the knee nor in pain relief in those in the placebo or treatment groups over a six-month duration. Bone marrow lesions also did not improve with the glucosamine group. The researchers used 3T MRI scans (an advanced radiologic imaging technique) to follow the patients’ disease progression. This does not mean that glucosamine does not work for some patients. Different formulations, such as glucosamine sulfate, were not used in this study.

Weight

This could not be an article on osteoarthritis if I did not talk about weight. Do you remember analogies from the SATs? Well here is one for you: Weight loss, weight loss, weight loss is to osteoarthritis as location, location, location is to real estate. In a recent study involving 112 obese patients, there was not only a reduction of knee symptoms in those who lost weight, but there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5). On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet

In a recent study, diet AND exercise trumped the effects of diet OR exercise alone (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a well-designed, randomized controlled single-blinded study with a duration of 18 months.

Researchers used a biomarker — IL6 — to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times per week.

Therefore, concentrate on lifestyle modifications if you want to see potentially disease-modifying effects. These include both exercise and diet. In terms of low-fat or nonfat milk, while the study had numerous flaws, if you drink milk, you might continue for the sake of osteoarthritis, but stay on the low end of consumption. And remember, the best potential effects shown are with weight loss and with a vegetable-rich diet.

References:

(1) uptodate.com. (2) Arthritis Care Res online. 2014 April 6. (3) JAMA. 2013;309:155-162. (4) Arthritis Rheum online. 2014 March 10. (5) Ann Rheum Dis online. 2014 Feb. 11. (6) JAMA. 2013;310:1263-1273.

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.

September marks the beginning of the academic calendar and noticeably shorter daylight hours. The pace of life tends to become more hectic. Although some stress is valuable to help motivate us and keep our minds sharp, high levels of constant stress can have detrimental effects on the body.

It is very likely that there is a mind-body connection when it comes to stress. In other words, it may start in the mind, but it can lead to acute or chronic disease promotion. Stress can also play a role with your emotions, causing irritability and outbursts of anger and possibly leading to depression and anxiety. Stress symptoms are hard to distinguish from other disorders but can include stiff neck, headaches, stomach upset and difficulty sleeping. Stress may also be associated with cardiovascular disease, with an increased susceptibility to infection from viruses causing the common cold and with cognitive decline and Alzheimer’s (1).

A stress steroid hormone called cortisol is released from the adrenal glands and can have beneficial effects in small bursts. We need cortisol in order to survive. Some of cortisol’s functions include raising glucose (sugar) levels when they are low and helping reduce inflammation and stress levels (2). However, when cortisol gets out of hand, higher chronic levels may cause inflammation, leading to disorders such as cardiovascular disease, as recent research suggests. Let’s look at the evidence.

Inflammation 

Inflammation may be a significant contributor to more than 80 percent of chronic diseases, so it should be no surprise that it is an important factor with stress. In a recent meta-analysis (a group of two observational studies), high levels of C-reactive protein (CRP), a biomarker for inflammation, were associated with increased psychological stress (3).

What is the importance of CRP? It may be related to heart disease and heart attacks. This study involved over 73,000 adults who had their CRP levels tested. The research went further to suggest that increased levels of CRP may result in more stress and also depression. With CRP higher than 3.0 there was a greater than twofold increase in depression risk. The researchers suggest that CRP may heighten stress and depression risk by increasing levels of different proinflammatory cytokines, inflammatory communicators among cells (4).

In one recent study, results suggested that stress may influence and increase the number of hematopoietic stem cells (those that develop all forms of blood cells), resulting specifically in an increase in inflammatory white blood cells (5). The researchers suggest that this may lead to these white blood cells accumulating in atherosclerotic plaques in the arteries, which ultimately could potentially increase the risk of heart attacks and strokes. Chronic stress overactivates the sympathetic nervous system — our “fight or flight” response — which may alter the bone marrow where the stem cells are found. This research is preliminary and needs well-controlled trials to confirm these results.

Infection

Stress may increase the risk of colds and infection. Cortisol over the short term is important to help suppress the symptoms of colds, such as sneezing, cough and fever. These are visible signs of the immune system’s infection-fighting response. However, the body may become resistant to the effects of cortisol, similar to how a type 2 diabetes patient becomes resistant to insulin. In one study of 296 healthy individuals, participants who had stressful events and were then exposed to viruses had a higher probability of catching a cold. It turns out that these individuals also had resistance to the effects of cortisol. This is important because those who were resistant to cortisol had more cold symptoms and more proinflammatory cytokines (6).

Diabetes and heart disease

When we measure cortisol levels, we tend to test the saliva or the blood. However, these laboratory findings only give one point in time. Thus, when trying to determine if raised cortisol may increase cardiovascular risk, the results are mixed. However, in a recent study, measuring cortisol levels from scalp hair was far more effective (7). The reason for this is that scalp hair grows slowly, and therefore it may contain three months’ worth of cortisol levels. The study showed that those in the highest quartile of cortisol levels were at a three times increased risk of developing diabetes and/or heart disease compared to those in the lowest quartile. This study involved older patients between the ages of 65 and 85.

Lifestyle changes can reduce effects of stress

Lifestyle plays an important role in stress at the cellular level, specifically at the level of the telomere, which determines cell survival. The telomeres are to cells as the plastic tips are to shoelaces; they prevent them from falling apart. The longer the telomere, the slower the cell ages and the longer it survives. In a recent study, those women who followed a healthy lifestyle — one standard deviation over the average lifestyle — were able to withstand life stressors better since they had longer telomeres (8).

This healthy lifestyle included regular exercise, a healthy diet and a sufficient amount of sleep. On the other hand, the researchers indicated that those who had poor lifestyle habits lost substantially more telomere length than the healthy lifestyle group. The study followed women 50 to 65 years old over a one-year period.

In another study, chronic stress and poor diet (high sugar and high fat) together increased metabolic risks, such as insulin resistance, oxidative stress and central obesity, more than a low-stress group eating a similar diet (9). The high-stress group members were caregivers, specifically those caring for a spouse or parent with dementia. Thus, it is especially important to eat a healthy diet when under stress.

Interestingly, in terms of sleep, the Evolution of Pathways to Insomnia Cohort study shows that those who deal with stressful events directly are more likely to have good sleep quality. Using medication, alcohol or, most surprisingly, distractors to deal with stress all resulted in insomnia after being followed for one year (10). Cognitive intrusions or repeat thoughts about the stressor also resulted in insomnia.

Psychologists and other health care providers sometimes suggest distraction from a stressful event, such as television watching or other activities, according to the researchers. However, this study suggests that this may not help avert chronic insomnia induced by a stressful event. The most important message from this study is that how a person reacts to and deals with stressors may determine whether they suffer from insomnia.

Constant stress is something that needs to be recognized. If it’s not addressed, it can lead to suppressed immune response or increased levels of inflammation. CRP is an example of an inflammatory biomarker that may actually increase stress. In order to address chronic stress and lower CRP, it is important to adopt a healthy lifestyle that includes sleep, exercise and diet modifications. Good lifestyle habits may also be protective against the effects of stress on cell aging.

References:

(1) Curr Top Behav Neurosci. 2014 Aug. 29. (2) Am J Physiol. 1991;260(6 Part 1):E927-E932. (3) JAMA Psychiatry. 2013;70:176-184. (4) Chest. 2000;118:503-508. (5) Nat Med. 2014;20:754-758. (6) Proc Natl Acad Sci U S A. 2012;109:5995-5999. (7) J Clin Endocrinol Metab. 2013;98:2078-2083. (8) Mol Psychiatry Online. 2014 July 29. (9) Psychoneuroendocrinol Online. 2014 April 12. (10) Sleep. 2014;37:1199-1208.

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.