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

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

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

Carbohydrates: Where are we with sugar?

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

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

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

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

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

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

Committee recommendations

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

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

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

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

Fats: Does it matter which type?

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

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

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

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

Where are we with red meat?

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

Overall food study index

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

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

Consequences

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

References:

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

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

Many of us give thanks for our health on Thanksgiving. Well, let’s follow through with this theme. While eating healthy may be furthest from our minds during a holiday, it is so important.

Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and increase your risk for chronic diseases, you can reverse this trend while staying in the traditional theme of what it means to enjoy a festive meal.

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

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

Breast cancer effect

We know that breast cancer risk is high among women, especially on Long Island. The risk for a woman getting breast cancer is 12.4 percent in her lifetime (2). Therefore, we need to do everything within reason to reduce that risk.

In a meta-analysis (a group of eight prospective or forward-looking studies), results show that women who were in the second to fifth quintile blood levels of carotenoids, such as alpha-carotene, beta-carotene and lutein and zeaxanthin, had significantly reduced risk of developing breast cancer (3).

Thus, there was an inverse relationship between carotenoid levels and breast cancer risk. Even modest amounts of carotenoids can have a resounding effect in potentially preventing breast cancer.

ALS: Lou Gehrig’s disease

ALS is a disabling and feared disease. Unfortunately, there are no effective treatments for reversing this disease. Therefore, we need to work double time in trying to prevent its occurrence.

In a meta-analysis of five prestigious observational studies, including The Nurses’ Health Study and the Health Professionals Follow-Up Study, results showed that people with the greatest amount of carotenoids in their blood from foods such as spinach, kale and carrots had a decreased risk of developing ALS and/or delaying the onset of the disease (4). This study involved over 1 million people with more than 1,000 who developed ALS.

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

Positive effects of healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are several obstacles to healthy eating. Two critical factors are presentation and perception.

Presentation is glorious for traditional dishes, like turkey, gravy and stuffing with lots of butter and creamy sauces. However, vegetables are usually prepared in either an unappetizing way — steamed to the point of no return, so they cannot compete with the main course — or smothered in cheese, negating their benefits, but clearing our consciences.

Many consider Thanksgiving a time to indulge and not think about the repercussions. Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. Why is it so important to change our mindsets? Believe it or not, there are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when most gain the predominant amount of weight for the entire year. However, people do not lose the weight they gain during this time (5). If you can fend off weight gain during the holidays, just think of the possibilities for the rest of the year.

Also, if you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (6). However, with a little Thanksgiving planning, you can reap significant benefits. What strategies should you employ for the best outcomes?

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

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

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

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

• Offer more healthy dessert options, like dairy-free pumpkin pudding and fruit salad. The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods.

You don’t have to be perfect, but improvements during this time period have a tremendous impact — they set the tone for the new year and put you on a path to success. Why not turn this holiday into an opportunity to de-stress, rest and reverse or prevent chronic disease by consuming plenty of carotenoid-containing foods.

References:

(1) Crit Rev Food Sci Nutr 2010;50(8):728–760. (2) SEER Cancer Statistics Review, 1975–2009, National Cancer Institute. (3) J Natl Cancer Inst 2012;104(24):1905-1916. (4) Ann Neurol 2013;73:236–245. (5) N Engl J Med 2000; 342:861-867. (6) www.heart.org. (7) Am J Clin Nutr 2010 Nov; 92(5):1165-1171.

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

Insomnia is an all-too-common complaint. Though the statistics vary widely, about 30 percent of Americans are affected, according to the most frequently used estimate (1). Women tend to be affected more than men. Insomnia is thought to have several main components: difficulty falling asleep, difficulty staying asleep, waking up before a full night’s sleep and sleep that is not restorative or restful (2).

Unlike sleep deprivation, patients have plenty of time for sleep. Having one or all of these components is considered insomnia. There is debate about whether or not it is actually a disease, though it certainly has a significant impact on patients’ functioning (3).

Insomnia is frustrating because it does not necessarily have one cause. Causes can include aging; stress; psychiatric disorders; disease states, such as obstructive sleep apnea and thyroid dysfunction; asthma; medication; and it may even be idiopathic (of unknown cause). It can occur on an acute (short-term), intermittent or chronic basis. Regardless of the cause, it may have a significant impact on quality of life. Insomnia also may cause comorbidities (diseases), two of which we will investigate further: heart failure and prostate cancer.

Fortunately, there are numerous treatments. These can involve medications, such as benzodiazepines like Ativan and Xanax. The downside of these medications is they may be habit forming. Nonbenzodiazepine hypnotics (therapies) include sleep medications, such as Lunesta (eszopiclone) and Ambien (zolpidem). All of these medications have side effects. We will investigate Ambien further because of recent warnings.

There are also natural treatments, involving supplements, cognitive behavioral therapy and lifestyle changes.

Let’s look at the evidence.

Heart failure

Insomnia may perpetuate heart failure, which can be a difficult disease to treat. In the HUNT analysis (Nord-Trøndelag Health Study), an observational study, results showed insomnia patients had a dose-dependent response for increased risk of developing heart failure (4). In other words, the more components of insomnia involved, the higher the risk of developing heart disease.

There were three components: difficulty falling asleep, difficulty maintaining sleep and nonrestorative sleep that is not restful. If one component was involved, there was no increased risk. If two components were involved, there was a 35 percent increased risk, although not statistically significant.

However, if all three components were involved, there was 350 percent increased risk of developing heart failure, even after adjusting for other factors. This was a large study, involving 54,000 Norwegians, with a long duration of 11 years.

Prostate cancer

Prostate cancer has a plethora of possible causes, and insomnia may be a contributor. Having either of two components of insomnia, difficulty falling asleep or staying asleep (sleep disruption), increased the risk of prostate cancer by 1.7 and 2.1 times, respectively, according to a recent observational study (5).

However, when looking at a subset of data related to advanced or lethal prostate cancer, both components, difficulty falling asleep and sleep disruption, independently increased the risk even further, 2.1 and 3.2 times, respectively.

This suggests that sleep is a powerful factor in prostate cancer, and other studies have shown that it may have an impact on other cancers, as well. There were 2,102 men involved in the study with a duration of five years. While there are potentially strong associations, this and other studies have been mostly observational. Further studies are required before any definitive conclusions can be made.

What about potential treatments?

Ambien: While nonbenzodiazepine hypnotics may be beneficial, this may come at a price. In a recent report by the Drug Abuse Warning Network, part of the Substance Abuse and Mental Health Services Administration, the number of reported adverse events with Ambien that perpetuated emergency department visits increased by more than twofold over a five-year period from 2005 to 2010 (6). Insomnia patients most susceptible to having significant side effects are women and the elderly. The director of SAMHSA recommends focusing on lifestyle changes for treating insomnia: by making sure the bedroom is sufficiently dark, getting frequent exercise, and avoiding caffeine.

In reaction to this data, the FDA required the manufacturer of Ambien to reduce the dose recommended for women by 50 percent (7). Ironically, sleep medication like Ambien may cause drowsiness the next day — the FDA is investigating if it is safe to drive after taking these medications the night before.

Magnesium: The elderly population tends to suffer the most from insomnia, as well as nutrient deficiencies. In a double-blinded, randomized controlled trial (RCT), the gold standard of studies, results show that magnesium had resoundingly positive effects on elderly patients suffering from insomnia (8).

Compared to a placebo group, participants given 500 mg of magnesium daily for eight weeks had significant improvements in sleep quality, sleep duration and time to fall asleep, as well as improvement in the body’s levels of melatonin, a hormone that helps control the circadian rhythm.

The strength of the study is that it is an RCT; however, it was small, involving 46 patients over a relatively short duration.

Cognitive behavioral therapy

In a recent study, just one 2½-hour session of cognitive behavioral therapy delivered to a group of 20 patients suffering from chronic insomnia saw subjective, yet dramatic, improvements in sleep duration from 5 to 6½ hours and decreases in sleep latency from 51 to 22 minutes (9). The patients who were taking medication to treat insomnia experienced a 33 percent reduction in their required medication frequency per week. The topics covered in the session included relaxation techniques, sleep hygiene, sleep restriction, sleep positions, and beliefs and obsessions pertaining to sleep. These results are encouraging.

It is important to emphasize the need for sufficient and good-quality sleep to help prevent, as well as not contribute to, chronic diseases, such as cardiovascular disease and prostate cancer. While medications may be necessary in some circumstances, they should be used with the lowest possible dose for the shortest amount of time and with caution, reviewing possible drug-drug and drug-supplement interactions.

Supplementation with magnesium may be a valuable step toward improving insomnia. Lifestyle changes including sleep hygiene and exercise should be sought, regardless of whether or not medications are used.

References:

(1) Sleep. 2009;32(8):1027. (2) American Academy of Sleep Medicine, 2nd edition, 2005. (3) Arch Intern Med. 1998;158(10):1099. (4) Eur Heart J. online 2013;Mar 5. (5) Cancer Epidemiol Biomarkers Prev; 2013;22(5):872–879. (6) SAMSHA.gov. (7) FDA.gov. (8) J Res Med Sci. 2012 Dec;17(12):1161-1169. (9) APSS 27th Annual Meeting 2013; Abstract 0555.

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.

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.