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Authors Posts by David Dunaief

David Dunaief

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Osteoporosis is a very tricky disease. What do osteoporosis, high blood pressure and high cholesterol have in common? They are all asymptomatic until the later stages. You can’t directly measure the progression or risk of osteoporosis fractures; you can only make an educated guess. The medical community does this mainly by using the Fracture Risk Assessment Tool (FRAX) score (1). FRAX estimates the 10-year risk of fracture in an untreated patient. You can find this tool at www.shef.ac.uk/FRAX.

There are a number of risks including genetics — family history, advanced age and demographics, with Asians being at highest risk — lifestyle, medications such as steroids and chronic diseases. A specific chronic disease that recently has come into focus is heart disease. We will discuss this in more detail. Also, it does not seem that diabetes, neither type 1 nor type 2, contributes to osteoporosis (2).

When we think of osteoporosis, we tend to associate it predominately with postmenopausal women; however, it does affect a significant number of men.

Treatments range from lifestyle modifications including diet, exercise and smoking cessation to supplements and medications. The medications that are considered first-line therapy are bisphosphonates, such as Reclast or Zometa (zoledronic acid), Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate) and Didronel (etidronate).

While all of these drugs have reduced fractures, recently zoledronic acid showed disappointing results in reducing fracture risk in the elderly population.

The relatively new medication on the block is Prolia (denosumab), an injectable human monoclonal antibody, that works through a different mechanism of action, though the result is the same; it blocks the osteoclastic (breakdown) activity of the bone (3). It has been shown to increase bone mineral density, or thickening of the bone, and reduce fracture risk. Prolia was approved at the end of 2012, so it has not been out long. Like bisphosphonates, it does have side effects.

As far as supplements go, the most exciting news is that melatonin may help to increase bone mineral density. Let’s look at the research.

The forgotten sex: men
Rarely are men the forgotten sex when it comes to medical research, but osteoporosis is an exception. Approximately one-third of fractures occur in men, resulting in a 37 percent mortality rate. One in five men over the age of 50 will experience a fracture with osteoporosis as a contributing factor. The predictions are that these rates will climb precipitously and that men need to be treated appropriately (4). Currently, less than 50 percent of men with osteoporosis are receiving treatment (5).

Is bariatric surgery useful?
Though bariatric surgery has been shown to have a number of benefits for many chronic diseases, osteoporosis is not one of them. In the Swedish Obesity Study, results show that women who underwent bariatric surgery were at 50 percent increased risk of fractures as well as long-term osteoporosis (6). The results in men were not statistically significant. The duration of the study was 25 years. The authors hypothesize that malnutrition may play a role in causing this effect. Supplementation may be important to overcome this, as well as frequent follow-ups with blood tests to track micronutrient levels.

Heart disease, really?
When we think of heart disease, we associate it with lots of complications, but osteoporosis is not typically one of them. Well, think again. In the Hertfordshire Cohort Study, results show that there was a significantly increased risk of wrist fracture of the radius in those with heart disease (7). These results were shown overall. However, when the sexes were analyzed separately, this effect held true for men but was not true for women, although the results in women did trend toward significance. This may be an example where men are at greater risk than women. Therefore, it may be important to think about osteoporosis when someone is diagnosed with heart disease, especially since it is not intuitive. Lifestyle factors could be a contributor to this association, as well as estrogen deficiency.

A bisphosphonate that disappointed
Bisphosphonates are the mainstay of treatment for osteoporosis, increasing bone density and decreasing fracture risk. However, zoledronic acid had surprisingly disappointing results in a randomized controlled trial (RCT) (8). Results showed that while zoledronic acid increased bone density over two years, it did not decrease the risk of fracture in elderly women in nursing homes. This does not necessarily have broad implications for other bisphosphonates. There were also weaknesses in this trial, the most serious being fracture risk was not a primary end point. Additionally, the study may have been too small. However, this still is a very intriguing study.

Melatonin for osteoporosis
What could melatonin possibly have to do with osteoporosis? Am I just trying to put you to sleep? No. There are surprisingly positive results with melatonin. In a recent very small RCT, melatonin in combination with 800 mg/day of vitamin D3 and 800 mg/day of calcium increased bone density significantly in the spine and femoral neck over a one-year period, compared to the control, or placebo, arm containing vitamin D3 and calcium of similar dosage (9).

Interestingly, with melatonin the amount of calcium excreted through the urine in a 24-hour measurement decreased by 12.2 percent. There was a dose-related curve, where melatonin 3 mg/day in combination with vitamin D3 and calcium showed greater results than 1 mg/day of melatonin, which showed significant results over the control arm. This was a preliminary study involving 81 postmenopausal women divided into three groups. Fracture risk reduction was not an end point. Larger studies with fracture risk as a primary end point are needed. Having said this, these results are exciting.

Though medications such as bisphosphonates and a monoclonal antibody may have an important place in the treatment of osteoporosis, not all medications may be equal. It is important to treat with lifestyle modifications including potentially supplements — melatonin, calcium and vitamin D3 — as well as diet, exercise and overall behavior modifications. Heart disease’s unexpected association with osteoporosis is a good reason to treat the whole patient, not just the disease. And don’t forget that men may have this disease too!

References:
(1) uptodate.com. (2) Exp Clin Endocrinol Diabetes. 2001;109 Suppl 2:S493-514. (3) epocrates.com. (4) iofbonehealth.org. (5) J Bone Miner Res. 2014;29:1929-1937. (6) ECO 2015. Abstract T8:OS3.3. (7) Osteoporos Int. 2015;26(7):1893-1901. (8) JAMA Intern Med. Online April 13, 2015. (9) J Pineal Res. Online June 3, 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 medicalcompassmd.com or consult your personal physician.

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We should all reduce the amount of added sugar we consume, because of its negative effects on our health. It is recommended that we get no more than 5 to 15 percent of our diet from added sugars and solid fats, combined. (1) However, approximately 13 percent of our diet is from added sugars alone. (2)

Is all sugar bad for us? The answer is not straightforward. It really depends on the source, and when I mention source, my meaning may surprise you.

We know that white, processed sugar is bad. But, I am constantly asked which sugar source is better: honey, agave, raw sugar, brown sugar or maple syrup? None are really good for us; they all raise the level of glucose (a type of sugar) in our blood. Two-thirds of our sugar intake comes from processed food, while one-third comes from sweetened beverages, according to the most recent report from the CDC. (2) Sweetened beverages are defined as sodas, sports drinks, energy drinks and fruit juices. That’s right: even 100 percent fruit juice can raise our glucose levels. Don’t be deceived because it says it’s natural and doesn’t include “added” sugar.

These sugars increase the risk of, and may exacerbate, chronic diseases, such as diabetes, heart disease, high blood pressure, cancer and obesity. This is such a significant problem that California’s legislature is considering adding warning labels to sweetened drinks. (3) The label would indicate that added sugars can increase the risk of diabetes and obesity, as well as tooth decay.

However, I did say that sugar’s source impacts its effect. Most fruits have beneficial effects in preventing disease, including diabetes, and do not raise sugar levels, even in patients with diabetes. It is a myth that whole fruit raises your sugar levels. However, dried fruits, fruit juice, and fruit concentrate do raise your sugar levels. Note that sugar extracted from fruit has an effect similar to that of sugar added to foods and sweetened beverages. Let’s look at the evidence.

Heart disease
When we think of sugar’s effects, heart disease is not usually the first disease that comes to mind. However, results from a 20-year study of 31,000 U.S. adults showed that, when comparing those who consumed the least amount of added sugar (less than 10 percent of calories daily), with those who consumed 10 to 25 percent and those who consumed more than 25 percent of daily calories from sugar, there were significant increases in risk of death from heart disease. (4) The added sugar was from foods and sweetened beverages, not from fruit and fruit juices.

This was not just an increased risk of heart disease, but an increased risk of cardiovascular death. This is a wake-up call to rein in our sugar consumption.

Obesity and weight gain
Does soda increase obesity risk? A recent assessment published in PLoS One, a highly respected, peer-reviewed journal, showed that it depends whether studies were funded by the beverage industry or had no ties to any lobbying groups.(5) Study results were mirror images of each other: studies not affiliated with the industry show that soda may increase obesity risk, while studies funded by the beverage industry show there may not be any association.

In studies without beverage industry funding, greater than 80 percent (10 of 12) showed associations between sugary drinks and increased weight or obesity, whereas with the beverage industry-funded studies, greater than 80 percent of them did not show this result (5 of 6). The moral of the story is that patients must be diligent in understanding studies’ funding, and if the results sound odd, they probably are. If this is the case, make sure to ask your doctor about the studies’ findings. Not all studies are equally well-designed.

Diabetes and the benefits of fruit
Diabetes requires the patient to limit or avoid fruit altogether, correct? This may not be true. Several recent studies may help change the long-standing, commonly held paradigm that fruit should be restricted in patients with diabetes and to prevent development of diabetes.

One study found that whole fruit may reduce the risk of diabetes by reducing inflammation and reducing insulin resistance. (6) Specifically, results demonstrated a reduction in the inflammatory biomarker hsCRP. Ultimately, this may result in better glucose control. A potential reason for these impressive results may be the high levels of flavonoids, specifically anthocyanins and flavones. Flavonoids, as a class, are phytochemicals (plant nutrients) that provide pigment to fruits and vegetables and may have substantial antioxidant activities. Substances that are high in these two flavonoids include red grapes, berries, tea and wine.

Another study, a meta-analysis that looked at three large studies, including the Nurses’ Health Study, NHS II, and the Health Professionals Follow-up Study, showed that those who consumed the highest amount of anthocyanins were likely to experience a 15 percent reduction in the development of type 2 diabetes. (7) Researchers compared those in the highest quintile of anthocyanin consumption with those in the lowest quintile.

Specifically, at least two servings of blueberries per week were shown to reduce the risk of diabetes by 23 percent, and at least five servings of apples and pears per week were also shown to reduce the risk by 23 percent. These were compared to those who consumed less than one serving per month. This is a small amount of fruit for a significant reduction.

From the same three studies, it was also shown that grapes, bananas and grapefruit reduce the risk of diabetes, while fruit juice and cantaloupe may increase risk. (8)

In still another diabetes study, involving those who were newly diagnosed with type 2 diabetes, the risk of increasing glucose levels was no greater in those who consumed more than two servings of fruit per day compared to those who consumed fewer than two servings per day. (9) For more details on this study, please review my March 14, 2013, article, “Diabetes: looking beyond obesity to other factors.”

The properties of flavonoids, for example found in whole fruit, may also result in anticancer and anticardiovascular disease properties, the opposite of added sugars. (10)

Chronic disease incidence and complications from these diseases have skyrocketed in the last several decades. Therefore, any modifiable risk factor should be utilized to decrease our risk. By keeping added sugar to a minimum in our diets, we could make great strides in the fight to maintain our quality of life as we age.
We don’t have to avoid sugar completely; we still can satiate a sweet tooth by eating ripe fruits. Our access to fruit, even off-season, has expanded considerably. The most amazing thing is that fruit may actually reduce the risk of diabetes, something for years we thought might exacerbate it.

References: (1) 2010 Dietary Guidelines for Americans. (2) cdc.gov. (3) reuters.com. (4) JAMA Intern Med. online February 03, 2014. (5) PLoS Med. 2013 Dec;10(12):e1001578. (6) J Nutr. 2014 Feb;144(2):202-8. (7) Am J Clin Nutr. 2012 Apr;95(4):925-33. (8) BMJ. online August 29, 2013. (9) Nutr J. published online March 5, 2013. (10) Plant Foods Hum Nutr. 2004 Summer;59(3):113-22.

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 medicalcompassmd.com or consult your personal physician.

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Ah, the warm summer months are upon us. I don’t want to be Debbie Downer, yet again, but I want to make you aware that tick season is here. In fact, according to Sam Telford, M.D., an infectious disease professor at Tufts University, we are at the peak of the season in the next few weeks to a month (1). He was talking about New England; however, the University of Rhode Island has raised its tick alert to the highest levels — red for both New England and the Mid-Atlantic states, including Long Island. Thus, it is good timing to talk about Borrelia burgdorferi, better known as the bacteria that causes Lyme disease. This bacteria is from the spirochete class and is typically found in the deer tick, also known as the blacklegged tick.

What do deer ticks look like? They are small and can be as tiny as a pencil tip or the size of a period at the end of a sentence. The CDC.gov site is a great resource for tick images and other information related to Lyme disease.

What if you have been bitten by a tick? The first thing you should do is remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick, for doing so may spread infectious disease (2). In the study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The NIH recommends not removing a tick with oil (3).

When a tick is removed within 36 to 48 hours, the risk of infection is quite low, according to the CDC (4). However, a patient can be given a prophylactic dose of the antibiotic doxycycline, one dose of 200 mg, if the erythema migrans, or bulls-eye rash — a red outer ring and red spot in the center —  has not occurred, and it is within 72 hours of tick removal (5). Those who took doxycycline had significantly lower risk of developing the bulls-eye rash and thus Lyme disease; however, treatment with doxycycline did have higher incidence of nausea and vomiting than placebo.

What are the signs and symptoms of Lyme disease? There are three stages of Lyme disease: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late-stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue (54 percent), muscle pain and joint pain (44 percent), headache (42 percent), neck stiffness (35 percent), swollen gland (23 percent) and fever (16 percent) (6).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory radiculoneuropathy (nerve roots of spinal cord). Late disseminated disease can cause Lyme arthritis (inflammation in the joints), heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (3).

How do we prevent this disease? According to the CDC, we should wear protective clothing, spray ourselves with insect repellent that includes at least 20 percent DEET, and treat our yards (4). Always check your skin for ticks after walking through a woody or tall grassy area. Many of us on Long Island have ticks in the backyard. My golden retriever, Buddy, whom I loved dearly, died of Lyme complications, and my mom’s golden retriever has tested positive.

DIAGNOSIS OF LYME DISEASE
Many times Lyme disease can be diagnosed within the clinical setting. However, when it comes to serologic or blood tests, the CDC recommends an ELISA test followed by a confirmatory Western blot test (4). However, testing immediately after being bitten by a tick is not useful, since the test will tend to be negative, regardless of infection or not (7). It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (8). These antibodies sometimes remain elevated even after successful treatment with antibiotics.

THE CARDIAC IMPACT
What are some of the complications of Lyme disease? Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death due to second or third degree atrioventricular (AV) node conduction (electrical) block. Among the 1.1 percent who had Lyme carditis, there were five sudden deaths (9). If there are symptoms of chest pain, palpitations, lightheadedness, shortness of breath or fainting, then clinicians should suspect Lyme carditis.

DOES CHRONIC LYME DISEASE EXIST?
There has been a debate about whether there is something called “chronic Lyme” disease. The research, unfortunately, has not shown consistent results that indicate that it exists. In the most recent report, chronic Lyme is refuted (10). In the analysis, the authors comment that the definition of chronic Lyme disease is obfuscated and that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes, according to several prospective trials. The authors do admit that there are prolonged neurologic symptoms in a subset population that may be debilitating even after the treatment of Lyme disease. These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment.

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When asked what was more important, longevity or healthy aging (quality of life), more people choose the latter. Why would you want to live a long life, but be miserable? Well, it turns out the two components are not mutually exclusive. I would like you to ponder the possibility of a third choice, “all of the above.” Would you change your answer and, instead of making a difficult choice between the first two, choose the third?
I frequently use the example of Jack LaLanne, a man best known for popularizing fitness. He followed and preached a healthy lifestyle, which included diet and exercise. He was quite a motivator for many and ahead of his time. He died at the ripe old age of 96.

This brings me to my next point, which is that the number of 90-year-olds is growing by leaps and bounds.

According to the National Institutes of Health, those who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those age 85 and older.

What do these patients have in common? According to one study, they tend to have fewer chronic morbidities or diseases. Thus, they tend to have a better quality of life with a greater physical functioning and mental acuity (2).

In a recent study of centenarians, genetics played a significant role. Characteristics of this group were that they tended to be healthy and then die rapidly, without prolonged suffering (3).

Another benchmark is the amount of health care dollars spent in their last few years. Statistics show that the amount spent for those who were in their 60s and 70s was significantly higher, three times as much, as for centenarians in their last two years (4).

Factors that predict one’s ability to reach this exclusive club may involve both genetics and lifestyle choices.

One group of people in the U.S. who lives longer lives on average than most is Seventh-day Adventists. We will explore why this might be the case and what lifestyle factors could increase our potential to maximize our healthy longevity. Exercise and diet may be key components of this answer. Now that we have set the tone, let’s look at the research.

EXERCISE
For all those who don’t have time to exercise or don’t want to spend the time, this next study is for you. We are told time and time again to exercise. But how much do we need, and how can we get the best quality? In a recent study, the results showed that 5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on lifespan by decreasing cardiovascular mortality and all-cause mortality (5).
Amazingly, even if participants ran less than six miles per week at a pace slower than 10-minute miles, and even if they ran only one to two days a week, there was still a decrease in mortality compared to nonrunners. Here is the kicker: those who ran for this very short of amount of time potentially added three years to their lifespan. There were 55,137 participants ranging in age from 18 to 100 years old.
An accompanying editorial to this study noted that more than 50 percent of people in the United States do not meet the current recommendation of at least 30 minutes of moderate exercise per day (6). Thus, this recent study suggests an easier target that may still provide significant benefits.

DIET
A long-standing paradigm is that we need to eat sufficient animal protein. However, there have been cracks developing in this façade of late, especially as it relates to longevity. In a recent observational study using NHANES III data, results show that those who ate a high-protein diet (greater 20 percent from protein) had a twofold increased risk of all-cause mortality, a four times increased risk of cancer mortality and a four times increased risk of dying from diabetes (7). This was over a considerable duration of 18 years and involved almost 7,000 participants ranging in age at the start of the study from 50 to 65.
However, this did not hold true if the protein source was from plants. In fact, a high-protein plant diet may reduce the risks, not increase them. The reason for this effect, according to the authors, is that animal protein may increase insulin growth factor-1 and growth hormones that have detrimental effects on the body.
Interestingly, those who are over the age of 65 may benefit from more animal protein in reducing the risk of cancer. However, there was a significantly increased risk of diabetes mortality across all age groups eating a high animal protein diet. The researchers therefore concluded that lower animal protein may be wise at least during middle age.
The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group whose emphasis is on a plant-based diet, and found that those who ate animal protein up to once a week had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (8). This was an observational trial with over 73,000 participants and a median age of 57 years old.

INFLAMMATION
You may have heard the phrase that inflammation is the basis for more than 80 percent of chronic disease. But how can we quantify this into something tangible? In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ longevity (9). In fact, if participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.
The takeaway from this study is that IL-6 is a relatively common biomarker for inflammation that can be measured with a simple blood test offered by most major laboratories. This study involved 3,044 participants over the age of 35 who did not have a stroke, heart attack or cancer at the beginning of the study.
The bottom line is that, although genetics is important for longevity, so too are lifestyle choices. A small amount of exercise, specifically running, can lead to a substantial increase in healthy lifespan. While calories are not equal, protein from plants may trump protein from animal sources in reducing the risk of mortality from all-cause, diabetes and heart disease.
This does not necessarily mean that one needs to be a vegetarian to see the benefits. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Thus, why not have a discussion with your doctor about testing to see if you have an elevated IL-6? Lifestyle modifications may be able to reduce these levels.

REFERENCES:
(1) nia.nih.gov. (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) CDC.gov. (5) J Am Coll Cardiol. 2014;64:472-481. (6) J Am Coll Cardiol. 2014;64:482-484. (7) Cell Metab. 2014;19:407-417. (8) JAMA Intern Med. 2013;173:1230-1238. (9) CMAJ. 2013;185:E763-E770.

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 and/or consult your personal physician.

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With warmer weather upon us, we now have long, sunny days, better moods and, of course, the beach.

However, longer sun exposure does increase the risk of skin cancer. Melanoma is the most serious skin cancer, but fortunately it is not the most common. Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) are more prevalent, in that order. Here, we will focus on these two types.

The incidences of these skin cancers are very difficult to pin down because they are not reported as readily.

However, most of us either know someone who has had these types of skin cancers or have had them ourselves. There were roughly 3.5 million nonmelanoma skin cancer treatments in the U.S. in 2006, with the number of treatments increasing 77 percent from 1992 to 2006 (1). SCC and BCC outcomes diverge, with the former having a higher risk of metastases compared to the latter, which tends to grow much slower (2).

These skin cancers may present in different ways. BCC may have a bump that is pearly, waxy, light-colored or pink or flesh-colored or brown. It may bleed, ooze and crust, but may not heal, and can be sunken in the middle (3). SCC has the appearance of a growing nodule. It may also be scaly or crusty and may have flat reddish patches. It may be a sore that also may not heal. It is found on sun-exposed areas, more commonly the forehead, hands, lower lip and nose (3). Interestingly, SCC develops over years of gradual UV sun exposure, while BCC develops more like melanoma through intense multiple sporadic burns (4).

The more well-known risks for these types of skin cancer include sun exposure (UV radiation), light skin, age, ethnicity and tanning beds (2). But there are other risk factors, such as manicures.

There are also ways to reduce risk with sunscreen reapplied every two hours, depending on what you are doing, but also NSAIDs (non-steroidal anti-inflammatories) and even vitamin B3.

Let’s look at the research.

BEYOND SKIN CANCER
Though nonmelanoma skin cancers (NMSCs) have far less potential to be deadly, compared to melanoma, there are other risks associated with them. In the CLUE II cohort study of over 19,000 participants, results show something very disturbing: A personal history of NMSC can lead to other types of cancer throughout the body (5). The increased risk of another type of cancer beyond NMSC is 103 percent in those with BCC and 97 percent in those with SCC, both compared to those who did not have a personal history of NMSC.

TANNING BEDS — NO SURPRISE
We know that tanning beds may be a cause for concern. Now the FDA has changed the classification of tanning beds from low to moderate risk and requires a warning that they should not be used by those under age 18 (6). The catch is that this does not have teeth; if tanning salons ignore the new rules, there is no punishment.

However, in a newly published prospective (forward-looking) study, results show that people’s responses to warnings depended on how the warnings were framed (7). Compared to the text-only FDA warning requirement, graphic warnings that emphasized the risks of skin cancer were more likely to help people stop using tanning beds, whereas graphic warnings that demonstrated the positive benefits of not using these devices had no effects. So you may have to scare the daylights out of those in their teens and early twenties.

MANICURE RISK, REALLY?
I am told women love manicures. Manicures cannot possibly be dangerous, right? Not so fast. It is not the actual manicure itself, but rather the drying process that poses a risk. In a recent prospective study, results show that drying lamps used after a manicure may increase the risk of DNA damage to the skin, which could lead to skin cancer, though the risk is small per visit (8). There were a lot of variables. The shortest number of visits to increase the risk of skin cancer was eight, but the intensity of the UVA irradiance varied considerably in 17 different salons. The median number of months it took to have carcinogenic potential with exposure was around 35, or roughly three years. The authors recommend either gloves or suntan lotion when using these devices, although both seem to be somewhat impractical with wet nails. It’s best to let your nails dry naturally.

VITAMIN B3 TO THE RESCUE
Many vitamins tend to disappoint when it comes to prevention. Well, hold on to your hat. This may not be the case for vitamin B3. In the recent Australian ONTRAC study, the results show that vitamin B3 reduced the risk of developing NMSC by 23 percent, compared to those who took a placebo (9). Even better was the fact that SCC was reduced by 30 percent.

The most interesting part about this study is that these results were in high-risk individuals who had a personal history of NMSC. The participants were given B3 (nicotinamide 500 mg) twice daily for one year.

After the patients discontinued taking B3, the benefits dissipated within six months. The study was on the small side, including 386 patients with two or more skin cancer lesions in the last five years, with a mean of eight lesions. The side effects were minimal and did not include the flushing (usually neck and facial redness) or headaches seen with higher levels of niacin, another derivative. The caveat is that this study was done in Australia, which has more intense sunlight. We need to repeat the study in the U.S. Nicotinamide is not expensive, and it has few side effects.

NSAIDs AS BENEFICIAL?
Results have been mixed previously in terms of NSAIDs and skin cancer prevention. However, a recent meta-analysis (nine studies of varying quality, with six studies considered higher quality) showed that especially nonaspirin NSAIDs reduced the risk of SCC by 15 percent compared to those who did not use them (10).

DIET — THE GOOD AND THE BAD
In terms of diet studies, there have been mixed positive and neutral results, especially when it comes to low-fat diets. These are notoriously difficult to run because the low-fat group rarely remains low fat.

However, in a prospective dietary study, results showed that effects on skin cancer varied depending on the foods. For those who were in the highest tertile of meat and fat consumption, compared to those in the lowest tertile, there was a threefold increased risk of a squamous cell cancer in those who had a personal history of SCC (11). But what is even more interesting is that those who were in the highest tertile of vegetable consumption, especially green leafy vegetables, experienced a 54 percent reduction in skin cancer, compared to those in the lowest consumption tertile.

Thus, know that there are modifiable risk factors that reduce the risk of non-melanoma skin cancer and don’t negatively impact your enjoyment of summer. There may be easy solutions to help prevent recurrent skin cancer, as well, that involve both medication and lifestyle modifications.

REFERENCES:
(1) Arch Dermatol. 2010;146(3):283. (2) uptodate.com. (3) nih.gov. (4) Br J Cancer. 2006;94(5):743. (5) J Natl Cancer Inst. 2008;100(17):1215-1222. (6) federalregister.gov. (7) Am J Public Health. Online June 11, 2015. (8) JAMA Dermatol. 2014;150(7):775-776. (9) ASCO 2015 Annual Meeting: Abstract 9000. (10) J Invest Dermatol. 2015;135(4):975-983. (11) Am J Clin Nutr. 2007;85(5):1401.

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 and/or consult your personal physician.

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Longer days are here again, and you can feel the jubilance of people coming out of hibernation after a long, hard winter. Summer weather will be here before you know it, and millions will be heading to the beaches.

What could possibly be wrong with this picture? With all these benefits, you need to be cognizant of cutaneous (skin) melanoma. It is small in frequency, compared to basal cell and squamous cell carcinomas, responsible for only about 5 percent of skin cancers; however, it is much more deadly.

STATISTICS
Unfortunately, melanoma is on the rise. Over the last 40 years from 1970 to 2009, its incidence has increased by 800 percent in young women and by 400 percent in young men (1). These were patients diagnosed for the first time between 18 and 39 years old. Overall, the risk is greater in men, with 1 in 37 afflicted by this disease in his lifetime. The rate among women is 1 in 56. It is predicted that in 2014, there will have been over 76,000 cases, with over 12 percent resulting in death (2).
Melanoma risk involves genetic and environmental factors. These include sun exposure that is intense but intermittent, tanning beds, UVA radiation used for the treatment of psoriasis, the number of nevi (moles), Parkinson’s disease, prostate cancer, family history and personal history. Many of these risk factors are modifiable (3).

PRESENTATION
Fortunately, melanoma is mostly preventable. What should you look for to detect melanoma at its earliest stages? In medicine, we use the mnemonic “ABCDE” to recall key factors to look for when examining moles. This stands for asymmetric borders (change in shape); border irregularities; color change; diameter increase (size change); and evolution or enlargement of diameter, color or symptoms, such as inflammation, bleeding and crustiness (4). Asymmetry, color and diameter are most important, according to guidelines developed in England (5).
It is important to look over your skin completely, not just partially, and have a dermatologist screen for potential melanoma. Screening skin for melanomas has shown a six-times greater chance of detecting them. Skin areas exposed to the sun have the highest probability of developing the disease. Men are more likely to have melanoma tumors on the back, while women are more likely to have melanoma on the lower legs, but they can develop anywhere (6).
In addition, most important to the physician, especially the dermatologist, is the thickness of melanoma. This may determine its probability to metastasize. In a recent retrospective (backward-looking) study, the results suggest that melanoma of >0.75 mm needs to not only be excised, or removed, but also have the sentinel lymph node (the closest node) biopsied to determine risk of metastases (7). A positive sentinel node biopsy occurred in 6.23 percent of those with thickness >0.75 mm, which was significantly greater than in those with thinner melanomas. When the sentinel node biopsy is positive, there is a greater than twofold increase in the risk of metastases. On the plus side, having a negative sentinel node helps relieve the stress and anxiety that the melanoma tumor has spread.

PREVENTION
The two most valuable types of prevention are clothing and sunscreen. Let’s look at these in more detail.

Clothing
Clothing can play a key role in reducing melanoma risk. The rating system for clothing protection is the ultraviolet protection factor (UPF). The Skin Cancer Foundation provides a list of which laundry additives, clothing and cosmetics protect against the sun (8). Clothing that has a UPF rating between 15 and 24 is considered good, 25 and 39 is very good, and 40 and 50 is excellent. The ratings assess tightness of weave, color (the darker the better), type of yarn, finishing, response to moisture, stretch and condition. The most important of these is the weave tightness (9).
Interestingly, the New York Times wrote about how major companies are producing sun protective clothing lines that are fashionable and lighter in weight. The article is entitled “Fashionable Options Reshape Sun-Protective Clothing,” published on July 17, 2013 (10).

Sunscreen
We have always known that sunscreen is valuable. But just how effective is it? In an Australian prospective (forward-looking) study, those who were instructed to use sun protective factor (SPF) 16 sunscreen lotion on a daily basis had significantly fewer incidences of melanoma compared to the control group members, who used their own sunscreen and were allowed to apply it at their discretion (11). The number of melanomas in the treatment group was half that of the control group’s over a 10-year period. But even more significant was a 73 percent reduction in the risk of advanced-stage melanoma in the treatment group. Daily application of sunscreen was critical.
The recommendation after this study and others like it is that an SPF of 15 should be used daily by those who are consistently exposed to the sun and/or are at high risk for melanoma according to the American Academy of Dermatology (12). The amount used per application should be about one ounce. However, since people don’t use as much sunscreen as they should, the academy recommends an SPF of 30 or higher. Note that SPF 30 is not double the protection of SPF 15. The UVB protection of SPFs 15, 30 and 50 are 93, 97 and 98 percent, respectively.
The problem is that SPF is a number that registers mostly the blocking of UVB but not so much the blocking of UVA1 or UVA2 rays. However, 95 percent of the sun’s rays that reach sea level are UVA. So what to do?
Sunscreens come in a variety of UV filters, which are either organic filters (chemical sunscreens) or inorganic filters (physical sunscreens). The FDA now requires broad-spectrum sunscreens pass a test showing they block both UVB and UVA radiation. Broad-spectrum sunscreens must be at least SPF 15 to decrease the risk of skin cancer and prevent premature skin aging caused by the sun. Anything over the level of SPF 50 should be referred to as 50+ (3).
The FDA also has done away with the term “waterproof.” Instead, sunscreens can be either water resistant or very water resistant, if they provide 40 and 80 minutes of protection, respectively. This means you should reapply sunscreen if you are out in the sun for more than 80 minutes, even with the most protective sunscreen (3). Look for sunscreens that have zinc oxide, avobenezene or titanium oxide; these are the only ones that provide UVA1 protection, in addition to UVA2 and UVB protection.
In conclusion, to reduce the risk of melanoma, proper clothing with tight weaving and/or sunscreen should be used. The best sunscreens are broad spectrum, as defined by the FDA, and should contain zinc oxide, avobenezene or titanium oxide to make sure the formulation not only blocks UVA2 but also UVA1 rays. It is best to reapply sunscreen every 40 to 80 minutes, depending on its rating. We can reduce the risk of melanoma occurrence significantly with these very simple steps.

REFERENCES:
(1) Mayo Clin Proc. 2012; 87(4): 328–334. (2) CA Cancer J Clin. 2014;64(1):9. (3) uptodate.com. (4) JAMA. 2004;292(22):2771. (5) Br J Dermatol. 1994;130(1):48. (6) Langley, RG et al. Clinical characteristics. In: Cutaneous melanoma, Quality Medical Publishing, Inc, St. Louis, 1998, p. 81. (7) J Clin Oncol. 201;31(35):4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23(6):264. (10) nytimes.com. (11) J Clin Oncol. 2011;29(3):257. (12) aad.org.

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 and/or consult your personal physician.

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It is very interesting that the amount of coverage by the lay press concerning thyroid nodules does not reflect the number of people who actually have them. In other words, more than 50 percent of people have thyroid nodules detectable by high resolution ultrasound (1); however, when I searched the New York Times website, the last time it wrote about them was in 2010.

Regardless, you can understand how coverage should be more in the forefront. Fortunately, most nodules are benign. A small percent, 4 to 6.5 percent, are malignant, and the number varies depending on the study (2). Thyroid nodules are being diagnosed more often incidentally on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck (3).

There is a conundrum of what to do with a thyroid nodule, especially when it is found incidentally. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (4). This is the cutoff point for asymptomatic nodules found with a radiologic exam. Most are asymptomatic. However, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (5).

FNA biopsy is becoming more common. In a recent study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (6). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. To make matters even more confusing, from 2001 to 2013, the number of thyroid cancers increased by 200 percent.

The study authors call for a need for more detailed guidelines, which are lacking for thyroid nodules.

Though the number of cancers diagnosed has increased, the mortality rate has remained relatively stable over several decades at about 1,500 patients per year (7). Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam.

DIFFERENTIATING WHEN FINE NEEDLE ASPIRATION RESULTS ARE INDETERMINATE
As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two modalities to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test. A meta-analysis (a group of six studies) of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies significantly but did not do a good job of identifying those who did have cancer (8).

On the other hand, a recent molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (9). This test was a combination of microRNA gene expression classifier with the genetic mutation panel. I know the test combination sounds confusing, but the important takeaway is that it was more effective than previous molecular tests in clarifying whether a patient had a benign or cancerous nodule.

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid. The trial used hospital-based patients, but follow-up studies need to include community-based practices.

IS A NEGATIVE FINE NEEDLE ASPIRATION DEFINITIVE?
We know that FNA is the gold standard for determining whether patients have malignant or benign thyroid nodules. However, a negative result on FNA is not always definitive for a benign thyroid nodule. When this occurs, it is referred to as a false negative result. In a recent retrospective (looking back at events) study, from the Longitudinal Health Insurance Database in Taiwan, 62 percent of thyroid nodules that were cancerous were diagnosed with one biopsy and 82 percent were found within the year after that biopsy (10). However, about 17 percent of patients needed more than two FNA biopsies, and 19 percent were diagnosed after one year with cancerous thyroid nodules.

THE POTENTIAL SIGNIFICANCE OF CALCIFICATION ON ULTRASOUND
Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (11). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk. The results demonstrated that more than half of the malignant thyroid nodules, 61 percent, had microcalcifications.

THE GOOD NEWS
As I mentioned above, most thyroid nodules are benign. The results of a recent study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (12).

This was a prospective (forward-looking) study involving 992 patients with between one and four benign thyroid nodules diagnosed cytologically (by looking at the cells) or by ultrasound. The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that the current paradigm might be altered and that after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

In considering risk factors, it’s important to note that those who had a normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had a high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (13).

The bottom line is that there is an urgent need for new guidelines regarding thyroid nodules. Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. We are getting better at diagnosing nodules. Why the death rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially two of the most common forms, follicular and papillary.

REFERENCES:
(1) AACE 2013 Abstract 1048. (2) Thyroid. 2005;15(7):708. (3) uptodate.com. (4) AACE 2013 Abstract 1048. (5) thyroid.org. (6) AAES 2013 Annual Meeting. Abstract 36. (7) AACE 2013 Abstract 1048. (8) Cancer. 2011;117(20):4582-4594. (9) J Clin Endocrinol Metab. Online May 12, 2015. (10) PLoS One. 2015;10(5):e0127354. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) J Clin Endocrinol Metab. 2006;91(11):4295.

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 and/or consult your personal physician.

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Triglycerides is a term that most of us recognize. This substance is part of the lipid (cholesterol) profile. However, this may be the extent of our understanding. Compared to the other substances, HDL (“good” cholesterol) and LDL (“bad” cholesterol), triglycerides are not covered much in the lay press and medical research tends to be less robust than for the other components. If I were to use a baseball analogy, triglycerides are the Mets, who get far less attention than their crosstown rivals, the Yankees.

But are triglycerides any less important? It is unclear whether a high triglyceride level is a biomarker for cardiovascular disease – heart disease and stroke – or an independent risk in its own right (1) (2). This debate has been going on for over 30 years. However, this does not mean it is any less important.

What are triglycerides? The most rudimentary explanation is that they are a kind of fat in the blood. Alcohol, sugars and excess calorie consumption may be converted into triglycerides.

Risk factors for high triglycerides include obesity, smoking, a high carbohydrate diet, uncontrolled diabetes, hypothyroidism (underactive thyroid), cirrhosis (liver disease), excessive alcohol consumption and some medications (3).

What levels are normal and what are considered elevated? According to the American Heart Association, optimal levels are <100 mg/dL; however, less than 150 mg/dL is considered within normal range. Borderline triglycerides are 150-199 mg/dL, high levels are 200-499 mg/dL and very high are >500 mg/dL (3).

While medicines that focus on triglycerides, fibrates and niacin, have the ability to lower them significantly, it is questionable whether this reduction results in clinical benefits, like reducing the risk of cardiovascular events. The ACCORD Study, a randomized controlled trial, questioned the effectiveness of medication; when these therapies were added to statins in type 2 diabetes patients, they did not further reduce the risk of cardiovascular disease and events (4). Instead, it seems that lifestyle modifications may be the best way to control triglyceride levels.

Let’s look at the evidence.

EXERCISE – TIMING AND INTENSITY
If you need a reason to exercise, here is really good one. I frequently see questions pertaining to optimal exercise timing and intensity. Most of the answers are vague, and the research is not specific. However, hold on to your hats, because a recent study may give the timing and intensity answer, at least in terms of triglycerides.

Study results showed that walking a modest distance with alacrity and light weight training approximately an hour after eating (postprandial) reduced triglyceride levels by 72 percent (5). However, if patients did the same workout prior to eating, then postprandial triglycerides were reduced by 25 percent. This is still good, but not as impressive. Participants walked a modest distance of just over one mile (2 kilometers). This was a small pilot study of 10 young healthy adults for a very short duration. The results are intriguing nonetheless, since there are few data that give specifics on optimal amount and timing of exercise.

EXERCISE TRUMPS CALORIE RESTRICTION
There is good news for those who want to lower their triglycerides: calorie restriction may not the best answer. In other words, you don’t have to torture yourself by cutting calories down to some ridiculously low level to get an effect. We probably should be looking at exercise and carbohydrate intake instead.

In a well-controlled trial, results showed that those who walked and maintained 60 percent of their maximum heart rate, which is a modest level, showed an almost one-third reduction in triglycerides compared to the control group (maintain caloric intake and no exercise expenditure) (6). Those who restricted their calorie intake saw no difference compared to the control. This was a small study of 11 young adult women.Thus, calorie restriction was trumped by exercise as a way to potentially reduce triglyceride levels.

CARBOHYDRATE REDUCTION, NOT CALORIE RESTRICTION
In addition, when calorie restriction was compared to carbohydrate reduction, results showed that carbohydrate reduction was more effective at lowering triglycerides (7). In this small but well-designed study, patients with nonalcoholic fatty liver disease were randomized to either a lower calorie (1200-1500 kcal/day) or lower carbohydrate (20 g/day) diet. Both groups significantly reduced triglycerides, but the lower carbohydrate group reduced triglycerides by 55 percent versus 28 percent for the lower calorie group. The reason for this difference may have to do with oxidation in the liver and the body as a whole. Both groups lost similar amounts of weight, so weight could not be considered a confounding or complicating factor. However, the weakness of this study was its duration of only two weeks.

FASTING VERSUS NONFASTING BLOOD TESTS
The paradigm has been that, when cholesterol levels are drawn, fasting levels provide a more accurate reading. Except this may not be true.

In a new analysis, fasting may not be necessary when it comes to cholesterol levels. NHANES III data suggests that nonfasting and fasting levels yield similar results related to all-cause mortality and cardiovascular mortality risk. The LDL levels were similarly predictive regardless of whether a patient had fasted or not. The researchers used 4,299 pairs of fasting and nonfasting cholesterol levels. The duration of follow-up was strong, with a mean of 14 years (8).

Why is this relevant? Triglycerides are an intricate part of a cholesterol profile. With regards to stroke risk assessment, nonfasting triglycerides possibly may be more valuable than fasting. In a study involving 13,596 participants, results showed that, as nonfasting triglycerides rose, the risk of stroke also rose significantly (9).

Compared to those who had levels below 89 mg/dL (the control), those with 89-176 mg/dL had a 1.3-fold increased risk of cardiovascular events, whereas those within the range of 177-265 mg/dL had a twofold increase, and women in the highest group (>443 mg/dL) had an almost fourfold increase. The results were similar for men, but not quite as robust at the higher end with a threefold increase.

The benefit of nonfasting is that it is more realistic and, according to the authors, also involves remnants of VLDL and chylomicrons, other components of the cholesterol profile that interact with triglycerides and may affect the inner part (endothelium) of the arteries.

What have we learned? Triglycerides need to be discussed, just as we review HDL and LDL levels regularly. Elevated triglycerides may result in heart disease or stroke. The higher the levels, the more likely there will be increased risk of mortality – both all-cause and cardiovascular. Therefore, we ideally should reduce levels to less than 100 mg/dL.

Lifestyle modifications using carbohydrate restriction and modest levels of exercise after a meal may be the way to go to the best results, though the studies are small and need more research. Nonfasting levels may be as important as fasting levels when it comes to triglycerides and the cholesterol profile as a whole; they potentially give a more realistic view of cardiovascular risk, since we don’t live in a vacuum and fast all day.

REFERENCES:
(1) Circulation. 2011;123:2292-2333. (2) N Engl J Med. 1980;302:1383–1389. (3) nlm.nih.gov. (4) N Engl J Med. 2010;362:1563-1574. (5) Med Sci Sports Exerc. 2013;45(2):245-252. (6) Med Sci Sports Exerc. 2013;45(3):455-461. (7) Am J Clin Nutr. 2011;93(5):1048-1052. (8) Circulation Online. 2014 July 11. (9) JAMA 2008;300:2142-2152.

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 and/or consult your personal physician.

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After a harsh winter, we pine for a mild and wonderful spring. The days get longer, trees and flowers bud and bloom, and grass becomes lush and green. It seems like heaven. But for people who suffer from seasonal allergic rhinitis, hay fever, seasonal allergies or whatever you would like to call it, life can be less than perfect. In fact, it can be downright miserable. You probably can rate an allergy season with your own built-in personal barometer, the sneeze factor. How many times are you, your friends or your colleagues sneezing?

Approximately 18 million adult Americans have had a diagnosis of seasonal allergies within the past year, about 7.5 percent of the population, and an additional 6.6 million children have this disorder, or about 9 percent, according to the Centers for Disease Control (1). Sadly, considering the number of people it affects, only a paltry amount of research has been published.

The triggers for allergies are diverse. They include pollen from leafy trees and shrubs, the lush grass and the beautiful flowering plants and weeds, with majority from ragweed (mostly in the fall), as well as fungus (summer and fall) (2).

What sparks allergies within the body? A chain reaction occurs in seasonal allergy sufferers. When the allergens (pollen in this case), which are foreign substances, interact with immunoglobulin E (IgE), antibodies that are part of our immune system, it causes mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response. The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it emulates a cold, but without the virus. If symptoms last more than 10 days and are recurrent, then it is more than likely you have allergies.

Risk factors for seasonal allergies are tied most strongly to family history and to having other personal allergies, such as eczema or food allergies, but also may include cigarette exposure, being male and, possibly, diet (4). If allergic rhinitis is not properly treated, complications such as ear infections, sinusitis, irritated throat, insomnia, chronic fatigue, headaches and even asthma can result (5).

To treat allergic rhinitis, there is a host of medications from classes including intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops, and leukotriene modifiers (second-line only). Let’s look at the evidence.

The best way to treat allergy attacks is to prevent them, but this is an arduous process that can mean closing yourself out from the enjoyment of spring by literally closing the windows, using the air-conditioning, and using recycling vents in your car.

The recent guidelines for treating seasonal allergic rhinitis with medications suggest that intranasal corticosteroids (steroids) should be used when quality of life is affected. If there is itchiness and sneezing, then second generation oral antihistamines may be appropriate (6). Three well-known inhaled steroids that do not require a prescription are Nasonex (mometasone), Nasocort (triamcinolone) and Flonase (fluticasone propionate). There does not seem to be a significant difference among them (7). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day.

Oral antihistamines, on the other hand, can be taken on an as-needed basis. Second-generation antihistamines have less sleepiness as a side effect than first-generation antihistamines. They include loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra).

SURPRISINGLY GOOD NEWS
Seasonal allergic rhinitis may actually be beneficial for longevity. In a recent study involving more 200,000 participants, results showed that those who had allergies had a 25 percent reduction in the risk of heart attacks, a 19 percent reduction in strokes, and a whopping 49 percent reduction in mortality (8). Remember two things: this is an observational trial, which means that it is not the best of trials, and don’t wish allergies on yourself. The reason for this effect may be at least partially attributable to the type of white blood cell expressed in the immune system. In other words, type 2 T helper (Th2) lymphocytes (white blood cells) are elevated with allergies instead of type 1 T helper (Th1) lymphocytes. Why is this important? Th2 is known to decrease cardiovascular disease, while Th1 is known to possibly increase cardiovascular disease. Unfortunately, the same cannot be said about asthma, where cardiovascular events are increased by 36 percent.

ALTERNATIVES
Butterbur (Petasites hybridus), an herb, may not just be for migraines. There are several small studies that indicate their efficacy in treating hay fever. In fact, in one study, results show that butterbur was as effective as cetirizine (Zyrtec) in treating this disorder (9). This was a small, randomized, controlled trial involving 131 patients.

In another randomized, controlled trial, results showed that high dose butterbur — 1 tablet given three times a day — was significantly more effective than placebo (10). The side-effects were similar in the placebo group and the butterbur group. The researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg. petasines per tablet) in the trial. The authors concluded that butterbur would be potentially useful for intermittent allergic rhinitis. The duration of treatment for this study was two weeks.

Still another study, this one a post-marketing study done as a follow-up to the previous study, showed that with butterbur Ze 339, symptoms improved in 90 percent of patients with allergic rhinitis (11). Interestingly, anti-allergic medications were coadministered in about half of the patient population, with no additional benefit over butterbur alone. There were 580 patients in this study, and the duration was 2 weeks.

Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the population.

The caveats to the use of butterbur are several. First, the studies were short in duration. Second, the leaf extract used in these studies was free of pyrrolizidine alkaloids (PAs); this is very important, since PAs may not be safe. Third, the dose was well-measured, which may not be the case with over-the-counter extracts. Fourth, you need to ask about interactions with prescription medications.

DIET
While there are no significant studies on diet, there is one review of literature that suggests that a plant-based diet may reduce symptoms of allergies, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma. This is according to the International Study of Asthma and Allergies in Childhood study in 13- to 14-year-old teens (12). In my clinical practice, I have seen patients who suffer from seasonal allergies improve and even reverse the course of allergies over time with a vegetable-rich, plant-based diet.

While allergies can be miserable, there are a significant number of over-the-counter and prescription options to help to reduce symptoms. Diet may play a role in the disease process by reducing inflammation, though there are no formal studies. There does seem to be promise with some herbs, especially butterbur. However, alternative supplements and herbs lack large, randomized clinical trials with long durations. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

REFERENCES
(1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) Allergy Clin Immunol. 2003;112(6):1021-31. (4) umm.edu. (5) J Allergy Clin Immunol. 2010;125(1):16-29. (6) Otolaryngol Head Neck Surg. online February 2, 2015. (7) Otolaryngol Head Neck Surg. 2003;129(1):16. (8) AAAAI 2014: Abstract 811. (9) BMJ 2002;324:144. (10) Arch Otolaryngol Head Neck Surg. 2004;130(12):1381-1386. (11) Adv Ther. 2006;23(2):373-84. (12) Eur Respir J. 2001;17(3):436-43.

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 and/or consult your personal physician.

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Weight loss should be a rather simple concept.  It should be solely dependent on energy balance: the energy (kilocalories) we take in minus the energy (kilocalories) we burn should result in weight loss if we burn more calories than we consume. However, it is much more complicated. Frankly, there are numerous factors that contribute to whether people who want to or need to lose weight can.

The factors that contribute to weight loss may depend on stress levels, as I noted in my previous article, “Ways to counter chronic stress.” High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone. (1)  Therefore, hormones contribute.

Another factor in losing weight may have to do with our motivators.  We will investigate this further. And we need successful weight management, especially when approximately 70 percent of the American population is overweight or obese and more than one-third is obese. (2)

Recently, obesity in and of itself was proclaimed a disease by the American Medical Association. Even if you don’t agree with this statement, excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis and a host of others, including autoimmune diseases.  Weight has an impact on all-cause mortality and longevity.

It is hotly debated as to which approach is best for weight loss.  Is it lifestyle change with diet and exercise, medical management with weight loss drugs, surgical procedures, or even supplements? The data show that, while medication and surgery may have their places, they are not replacements for lifestyle modifications; these modifications are needed no matter what route is followed.

But, the debate continues as to which diet is best. We would hope patients would not only achieve weight loss, but also overall health.

Let’s look at the evidence.

LOW-CARBOHYDRATE DIETS VS. LOW-FAT DIETS
Is a low-carbohydrate, high-fat diet a fad?  It may depend on diet composition.  In a newly published study of a randomized controlled trial (RCT), the gold standard of studies, results showed that a low-carbohydrate diet was significantly better at reducing weight than low-fat diet, by a mean difference of 3.5 kg lost (7.7 lbs.), even though calories were similar and exercise did not change. (3)
The authors also note that the low-carbohydrate diet reduced cardiovascular disease risk factors in the lipid (cholesterol) profile, such as decreasing triglycerides (mean difference 14.1 mg/dl) and increasing HDL (good cholesterol). Patients lost 1.5 percent more body fat on the low-carbohydrate diet, and there was a significant reduction in inflammation biomarker, C-reactive protein (CRP). There was also a reduction in the 10-year Framingham risk score. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group. This study was 12 months in duration with 148 participants, predominantly women, with a mean age of 47, none of whom had cardiovascular disease or diabetes, but all of whom were obese or morbidly obese (BMI 30-45 kg/m2).
Although there were changes in biomarkers, there was a dearth of cardiovascular disease clinical endpoints.  This begs the question; does a low-carbohydrate diet really reduce the risk of developing cardiovascular disease (CVD) or its subsequent complications?  The authors indicated this was a weakness since it was not investigated.
Digging deeper into the diets used, it’s interesting to note that the low-fat diet was remarkably similar to the standard American diet; it allowed 30 percent fat, only 5 percent less than the 35 percent baseline for the same group.  In addition, it replaced the fat with mostly refined carbohydrates, including only 15 to 16 g/day of fiber.
The low-carbohydrate diet participants took in an average of 100 fewer calories per day than participants on the low-fat diet, so it’s no surprise that they lost a few more pounds over a year’s time.
Patients in both groups were encouraged to eat mostly unsaturated fats, such as fish, nuts, avocado and olive oil.
As David Katz, M.D., founding director of Yale University’s Prevention Research Center noted, this study was more of a comparison of low-carbohydrate diet to a high-carbohydrate diet than a comparison of a low-carbohydrate diet to a low-fat diet. (4)
Another study actually showed that a Mediterranean diet, higher in fats with nuts or olive oil, compared to a low-fat diet showed a significant reduction in cardiovascular events- clinical endpoints not just biomarkers. (5)  However, both of these studies suffer from the same deficiency: comparing a low-carbohydrate diet to a low-fat diet that’s not really low-fat.

DIET COMPARISONS
Interestingly, in a meta-analysis (a group of 48 RCTs), the results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet), the results showed similar amount of weight loss compared to no intervention at all. (6)  Both diet types resulted in about 8 kgs. (17.6 lbs.) of weight loss at six months versus no change in diet.  However, this meta-analysis did not make it clear whether results included body composition changes or weight loss alone.
In an accompanying editorial discussing the above meta-analysis, the author points out that it is unclear whether a low-carbohydrate/high animal protein diet might result in adverse effects on the kidneys, loss of calcium from the bones, or other potential deleterious health risks.  The author goes on to say that for overall health and longevity and not just weight loss, micronutrients may be the most important factor, which are in nutrient-dense foods.
A recent Seventh-day Adventist trial would attest to this emphasis on a micronutrient-rich, plant-based diet with limited animal protein.  It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet. (7)

PSYCHE
Finally, the type of motivator is important in whatever our endeavors.  Weight loss goals are no exception.  Let me elaborate.  A recently published study followed West Point cadets from school to many years after graduation and noted who reached their goals. (8)  The researchers found that internal motivators and instrumental (external) motivators were very important.  The soldiers who had an internal motivator, such as wanting to be a good soldier, were more successful than those who focused on instrumental motivators, such as wanting to become a general.   Those who had both internal and instrumental motivators were not as successful as those with internal motivators alone.  In other words, having internal motivators led to an instrumental consequence of advancing their careers.
When it comes to health, an instrumental motivator, such weight loss, may be far less effective than focusing on an internal motivator, such as increasing energy or decreasing pain, which ultimately could lead to an instrumental consequence of weight loss.
There is no question that dietary changes are most important to achieving sustained weight loss. However, we need to get our psyches in line for change. Hopefully, when we choose to improve our health, we don’t just focus on weight as a measure of success.  Weight loss goals by themselves tend to lead us astray and to disappoint, for they are external motivators.  Focus on improving your health by making lifestyle modifications.  This tends to result in a successful instrumental consequence.

REFERENCES
(1) Psychoneuroendocrinol. online 2014 April 12.  (2) JAMA 2012;307:491–497.  (3) Ann Intern Med. 2014;161(5):309-318.  (4) Huffington Post. Sept 2, 2014.  (5) N Engl J Med. 2014 Feb 27;370(9):886.  (6) JAMA. 2014;312(9):923-933.  (7) JAMA Intern Med. 2013;173:1230-1238.  (8) Proc Natl Acad Sci U S A. 2014;111(30):10990-5.

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 and/or consult your personal physician.

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