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 of 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 their lifetimes. The rate among women is 1 in 56. It is predicted that in 2014, there will be over 76,000 cases, with over 12 percent of these 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 can play a key role in reducing melanoma risk. The rating system for clothing protection is ultraviolet protection factor. 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 to 39 is very good and 40 to 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” (10).

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 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 recommendations 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 percent, 97 percent 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 the sun’s rays that reach sea level are UVA. So what to do?

Sunscreens come in a variety of UV filters that 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 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, avobenzone 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, avobenzone 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; 87:328–334. (2) CA Cancer J Clin. 2014;64:9-29. (3) uptodate.com. (4) JAMA. 2004;292:2771-2776. (5) Br J Dermatol. 1994;130:48-50. (6) Langley R. G. et al. Clinical characteristics. In: Cutaneous Melanoma, Third Edition. St. Louis, Mo., Quality Medical Publishing Inc. 1998. p. 81. (7) J Clin Oncol. 2013;31:4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23:264-274. (10) nytimes.com. 2013 July 17. (11) J Clin Oncol. 2011;29:257-263. 12 aad.org.

*If you would like to see a specific topic covered in Medical Compass, please email  [email protected].

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 and/or consult your personal physician.

Cardiovascular disease is anything but boring; what we know about it is constantly evolving.  New information comes along all the time, which on the whole is a good thing.  Even though this disease has been on the decline, it is still the number one killer of Americans, responsible for about one million deaths per year.1  However, not all studies nor all analyses on the topic are created equal.  Therefore, I thought it apropos to present a quiz on cardiovascular disease myths and truths.

Without further ado, here is a challenge to your cardiovascular disease IQ.  The questions below are true or false.  The answers and evidence are provided after.

1) Saturated fat is good for us, but processed foods and trans-fats are unhealthy.

2) Fish oil supplements will help reduce the risk of cardiovascular disease and mortality.

3) Fiber has significantly beneficial effects on heart disease prevention.

4) Unlike sugary sodas and drinks, diet soda is most likely not a contributor to this disease.

5) Vitamin D deficiency may contribute to cardiovascular disease.

Now that was not so difficult. Or was it?  The answers are as follows: 1-F, 2-F, 3-T, 4-F, 5-T.  So how did you do? Regardless of whether you know the answers, the reasons are even more important to know.  Let’s look at the evidence. 

Saturated Fat

Most of the medical community has been under the impression that saturated fat is not good for us.  We need to limit the amount to no more than 10% of our diet.  But is this true?  The results of a newly published meta-analysis (a group of 72 randomized clinical trials and observational studies) would upend this paradigm.2   While saturated fat did not decrease the risk of cardiovascular disease, it did not significantly increase the risk either.   Also, the results showed that trans-fats increase the risk of this disease. Of course trans-fats are a processed fat, so this is something that most of us would agree upon.  And in the clinical trials portion of the meta-analysis, omega-3 and omega-6 polyunsaturated fats did not significantly reduce the risk of cardiovascular disease. 

Does this mean that we can go back to eating saturated fats with impunity?  Well, there were weaknesses and flaws with this study.  The authors only looked at the one dimension of fat.  Their comparison was based on the upper-third of intake of one type of fat versus the lower-third of intake of the same type of fat (whether it was saturated fat or a type of unsaturated fat).  It did not consider whether saturated fat was substituted with refined grains or unsaturated fatty acids.  Also, what was the source of saturated fats, animal or plant, and did these sources also contain unsaturated fats as well, like olive oil or nuts which contain good fats?  Therefore, there are many unanswered questions and potentially several significant flaws with this study.

While I respect the New York Times, I was a bit surprised to see Mark Bittman’s March 25, 2014 column, “Butter is Back,” referencing the new meta-analysis above. Many of his articles in the past have contributed to the health and wellness of his readers. However, he misses the boat by promoting butter and other sources of saturated animal fat, such as cheese, pork and the skin from chicken. I think he does a disservice to his readers, making statements that are downright dangerous and hopefully will not result in more cardiovascular disease.

The meta-analysis above, which Bittman uses to buoy his arguments, does not differentiate among plant or animal saturated fat sources.  But in one that does, the researchers found saturated fats from animal sources increased cholesterol and the risk of cardiovascular disease.3  Also in another study, specifically using unsaturated fats in place of saturated fat reduced the risk of this disease.4, 5

Fish oil

There is whole industry built around fish oil and reducing the risk of cardiovascular disease.  Yet the data don’t seem to confirm this theory.  In the latest study, the age-related eye disease study 2 (AREDS2), unfortunately, 1 g of fish oil (long chain omega-3 fatty acids) daily did not demonstrate any benefit in the prevention of cardiovascular disease nor its resultant mortality.6  This study was done over a five-year period in the elderly with macular degeneration.  The cardiovascular primary endpoint was a tangential portion of the ophthalmic AREDS2.  This does not mean that fish, itself, falls into that same category, but for now there does not seem to be a need to take fish oil supplements for heart disease, except potentially for those with very high triglycerides.  Fish oil, at best, is controversial ; at worst, it has no benefit with cardiovascular disease.

Fiber

We know that fiber tends to be important for a number of diseases, and cardiovascular disease does not appear to be an exception.  In a meta-analysis, involving 22 observational studies, the results showed a linear relationship between fiber intake and decreased in risk for developing cardiovascular disease.7  In other words, for every 7 grams of fiber consumed, there was 9% reduced risk in developing the disease.  It did not matter the source of the fiber from plant foods; vegetables, grains and fruit all decreased the risk of cardiovascular disease.  This did not involve supplemental fiber, like that found in Fiber One or Metamucil.  To give you an idea about how easy it is to get a significant amount of fiber, one cup of lentils has 15.6 grams of fiber, one cup of raspberries or green peas has almost 9 grams, and one medium-size apple has 4.4 grams.  Americans are sorely deficient in fiber. 8

Diet Soda

An upcoming presentation at the American College of Cardiology examines the Women’s Health Initiative: the study suggests that diet soda may increase the risk of heart disease.9  In those drinking two or more cans per day, defined as 12 ounces per can, there was a 30% increased risk of a cardiovascular event, such as an a stroke or heart attack, but an even greater risk of cardiovascular mortality, 50%, over 10 years.  These results took into account confounding factors like smoking, diabetes, high blood pressure, and obesity.  This study involved over 56,000 postmenopausal women for almost a nine-year duration.

Vitamin D

The results of a recent observational study in the elderly suggest that vitamin D deficiency may be associated with cardiovascular disease risk.  The study showed that those whose vitamin D levels were low had increased inflammation, demonstrated by elevated biomarkers including C-reactive protein (CRP).10  This biomarker is related to inflammation of the heart, though is not as specific as one would hope.

Beware in regards to saturated fat.  If a study looks like an outlier or too good to be true, then probably it is.  I would not run out and get a cheeseburger just yet. However, study after study has shown benefit with fiber.  So if you want to reduce the risk of cardiovascular disease, consume as much whole food fiber as possible.  Also, since we live in the northeast, consider taking at least 1000 IUs of vitamin D daily.  This is a simple way to help thwart the risk of the number one killer.

References:

1 uptodate.com.  2 Ann Intern Med. 2014;160(6):398-406. 3 JAMA 1986;256(20):2623. 4 Am J Clin Nutr. 2009;99(5):1425-32. 5 Cochrane Database Syst Rev. 2012:5;CD002137. 6 JAMA Intern Med. Online March 17, 2014.  7 BMJ 2013; 347:f6879.  8 Am J Med. 2013 Dec;126(12):1059-67.e1-4. 9 ACC Scientific Sessions 2014; Abstract 917-05.  10 J Clin Endocrinol Metab online February 24, 2014. 

With spring officially here and — believe or not — beach weather around the corner, millions of American will expose their toes. Some will be more self-conscious about it than others, because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails, but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many patients are bothered by this disorder. Most patients consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1). Onychomycosis is not easy to treat and can be quite uncomfortable.

Onychomycosis affects approximately 8 percent of the population (2). The risk factors are unclear, but may be relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected by it (3).

There are a number of organisms that can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A test commonly used to differentiate the organisms is a KOH (potassium hydroxide) preparation, which is a simple microscopic exam of skin and nail shavings. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of the autoimmune disease psoriasis.

There are a plethora of therapies available for treatment. These range from over-the-counter alternative therapies to prescription topical medications to systemic, or oral, prescription therapies to laser therapies and, finally, surgery. I am regularly asked which treatment works best.

With all of these options, how is one to choose? Well, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. So there is no overnight success. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Fortunately, most cases of nail fungus are benign, with only a fraction leading to infections. Infection is most common in those with diabetic neuropathy, where the patient loses feeling in their feet.

Let’s look at the evidence.

Oral antifungals

There are several options for oral antifungals, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These medications tend to have the greatest success rate, but the disadvantages are their side effects.

In a small but randomized controlled trial, terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of the fungus in their toenails with terbinafine, whereas 21 percent and 32 percent experienced these benefits with fluconazole, depending on the duration. The patients in the terbinafine group were treated with 250 mg of drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of drug for either 12 weeks or 24 weeks, with those in the 24-week group experiencing the better results. Thus, this would imply that terbinafine is the more effective drug. This is a small trial, but the results are intriguing. The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine. Its advantages are the efficacy and the duration.

Another approach to reduce side effects is to give oral antifungals in a pulsed fashion. In a RCT, fluconazole 150 mg or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, the efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, the disadvantages are that it takes approximately a year of daily use, and its efficacy is not as great as the oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In this trial, ciclopirox had to be applied daily for 48 weeks. These results were in patients with mild to moderate levels of fungus in the surface area of the infected nails.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. To make matters worse, many of the laser treatments are not covered by insurance, and they can be expensive. Another research paper that reviewed the current literature concluded that laser therapies are lacking in randomized clinical trials (10).

The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if it is effective.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Additionally, partial improvement occurred in the toenails of 10 patients. But what is more interesting is that all 18 patients rated the results as either “satisfying” or “very satisfying.” The gel was applied daily for 48 weeks. The advantage is low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and the lower efficacy compared to oral antifungals.

So when it comes to onychomycosis, what should one do? None of the treatments are perfect. Oral medications tend to be the most efficacious, but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance. If you decide on this approach, discuss it with your doctor; there are appropriate precautionary tests, such as liver enzyme monitoring with terbinafine (Lamisil), that need to be done on a regular basis. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better initial choice. No matter what you and your physician agree upon as the appropriate treatment, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196;Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Dermatol Online J. 2013 Sep. 14;19:19611. (11) J Am Board Fam Med. 2011;24:69–74.

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.

Most of us know that type 2 diabetes is an epidemic in America and continues to grow. Type 2 diabetes was thought to be an adult-onset disease, but more and more children and adolescents are affected as well. The most recent statistics show that 50% of teens with diabetes between the ages of 15 and 19 have type 2 (1). Thus, this disease is pervasive throughout the population.

Let’s test our diabetes IQ. See if you can determine if the following are true or false. Don’t worry, you won’t be judged or graded for wrong answers; this is meant to encourage you to learn more.

1) Whole fruit should be limited or avoided.

2) Soy has detrimental effects with diabetes.

3) Plant fiber provides too many carbohydrates.

4) Coffee consumption contributes to diabetes.

5) Bariatric surgery is an alternative to lifestyle changes.

My goal is to help debunk type 2 diabetes myths. All of these statements are false.

Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has always been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Recent studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (2).  In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (3).

In yet another study, researchers looked at different whole fruits to determine their impacts on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (4). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe. To read more detail about some of these studies, please see my article, “Sugar, Sugar.” Fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

We know fiber is important in a host of diseases, and it is not any different in diabetes. In the Nurses’ Health Study and NHS II, two very large prospective (forward-looking) observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (5). Researchers looked at lignans, a type of plant fiber, specifically examining metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors therefore encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include: flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (6). The researchers could not determine which plants contributed the most benefit. They believe the effect is from antioxidant activity.

Soy and kidney function

Soy sometimes has a negative association. However, in diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (7). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better. This was a small but randomized controlled trial, considered the gold standard of studies, over a four-year period with 41 participants. The control group’s diet consisted of 70% animal protein and 30% vegetable protein, while the treatment group’s consisted of 35% animal protein, 35% textured soy protein and 30% vegetable protein. This is very important since diabetes patient are 20-to-40 times more likely to develop nephropathy than those without diabetes (8). It appears that soy protein puts substantially less stress on the kidneys than animal protein, which creates nitrogenous waste products. However, those who have hypothyroidism should avoid soy.

Coffee

Coffee is a staple in America and in my household. It is one thing my wife would never let me consider taking away. Well she and the rest of the coffee-drinking portion of the country can breathe a big sigh of relief when it comes to diabetes. There is a new meta-analysis (involving 28 prospective studies) that shows coffee decreases the risk of developing diabetes (9). It was a dose-dependent effect; two cups decreased the risk more than one cup. Interestingly, it did not matter whether it contained caffeine or was decaffeinated. This suggests that caffeine is not necessarily the driving force behind the effect of coffee on diabetes. The authors surmise that other compounds, including lignans, which have antioxidant effects, may play an important role. The duration of the studies ranged from 10 months to 20 years, and the database was searched from 1966 to 2013, with over one million participants.

Bariatric Surgery

In the last few years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m2) and obese (BMI >30 kg/m2) diabetes patients. In a meta-analysis of bariatric surgery (involving 16 RCTs and observational studies), the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (10). During this time period, 72% of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss. However, after 10 years without proper management involving lifestyle changes, only 36% remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintain long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home messages are: don’t avoid whole fruit; soy is potentially valuable; fiber from plants may play a very powerful role in preventing and treating diabetes; and coffee may help prevent diabetes. Thus, the overarching theme is that you can’t necessarily go wrong with a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to increase the likely durability over 10 or more years.

References:

(1) JAMA. 2007;297:2716-2724. (2) Nutr J. 2013 Mar. 5;12:29. (3) Am J Clin Nutr. 2012 Apr.;95:925-933. (4) BMJ online 2013 Aug. 29. (5) Diabetes Care. online 2014 Feb. 18. (6) Br J Nutr. 2005;93:393–402. (7) Diabetes Care. 2008;31:648-654. (8) N Engl J Med. 1993;328:1676–1685. (9) Diabetes Care. 2014;37:569-586. (10) Obes Surg. 2014;24:437-455.

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.

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% of calories daily), with those who consumed 10-25% and those who consumed more than 25% of daily calories from sugar, there were significant increases in risk of death from heart disease, 30% and a 275%, respectively (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.

Testosterone is a hot topic in the news lately. Men are going through andropause or have unusually low testosterone (hypogonadism), or as it is most recently referred by the pharmaceutical industry: “Low T.” We are bombarded continually with ads suggesting that men should talk to their doctors about Low T. The formal name for treatment is androgen replacement therapy.

Is this all hype, or is this a serious malady that needs medical attention? The short answer is it depends on the candidate. The best candidates have deficient testosterone levels and are symptomatic.

The greatest risk factor for lower testosterone is age. As men age, the level of testosterone decreases. Respectively, 20, 30 and 50 percent of those who are in their 60s, 70s and 80s have total testosterone levels of less than 320 ng/dL. 1 However, some of the pharmaceutical ads would have you think that most men over 40 should seek treatment. Treatments include gels, transdermal patches and injections.

While real estate is all about “location, location, location,” with testosterone “caution, caution, caution” should be used.

Who are the most appropriate candidates for therapy? Those who have symptoms including lack of sexual desire, fatigue and lack of energy. However, what is scary is that around 25 percent of patients are getting scripts for testosterone without first testing their blood levels to determine if they have a deficiency.2 A simple blood test can measure total testosterone, as well as free and weakly bound levels at mainstream labs.

The number of testosterone scripts has increased threefold from 2001-11 for men more than 40 years old.3 Either we have discovered vast numbers of men with low levels or, more likely, marketing has caused the number of scripts to outstrip the need.

What are the risks and benefits of treating testosterone levels?

Is testosterone treatment really the fountain of youth?

There are benefits reported for those who actually have significantly deficient levels. Benefits may include improvements in muscle mass, strength, mood and sexual desire.4

However, several studies have recently suggested that testosterone therapy may increase the risk of cardiovascular disease, including stroke, heart disease and even death. These are obviously serious side effects. It also may cause acquired hypogonadism by shrinking the testes, resulting in a dependency on exogenous, or outside, testosterone therapy.

When testosterone is given, it may be important to also test PSA levels.5 If they increase by more than 1.4 ng/ml over a three-month period, then it may be wise to have a discussion with your physician about considering discontinuing the medication. You should not stop the medication without first talking to your doctor, and then a consult with an urologist may be appropriate. If the PSA is greater than 4.0 ng/ml initially, treatment should probably not be started without a urology consult.

How can you raise testosterone levels and improve symptoms without hormone therapy? Lifestyle changes, including losing weight, exercising and altering dietary habits, have shown promising results.

Let’s look at the evidence:

Cardiovascular risk

In the newest study, results showed that men were at significantly increased risk of experiencing a heart attack within the first three months of testosterone use.6 There was an overall 36 percent increased risk. When stratified by age, this was especially true of men who were 65 and older. This population had a greater than twofold risk of having a heart attack. The risk may have to do with an increased number of red blood cells with testosterone therapy. Those who were younger showed a trend toward increased risk, but did not meet statistical significance.

However, if the patient was younger than 65 and had heart disease, there was a significant twofold greater risk, but those without did not show risk. This does not mean there is no risk for those who are “healthy” and younger, it just means the study did not show it. This observational study compared over 50,000 men who received new testosterone scripts with over 150,000 men who received scripts for erectile dysfunction drugs: phosphodiesterase type 5 (PDE5) inhibitors, including tadalafil (Cialis) and sildenafil (Viagra). PDE5 inhibitors have not demonstrated this cardiovascular risk.

Unfortunately, this is not the only study that showed potential cardiovascular risks. Another recent study reinforces these results. In 2013, results showed that there was an increased risk of stroke, heart attack and death after three years of testosterone use.7 Ultimately, it found a 30 percent greater chance of cardiovascular events.

What is worse is that risk was significant in both those with a history of heart disease and those without. This was a retrospective study involving 1,200 men with a mean age of 60.

We need randomized controlled trials to make a more definitive association. Still, these are two large studies that suggest increased risk.

If you already have heart disease, be especially careful when considering testosterone therapy.

FDA response

As of Jan. 31, the FDA, which approved testosterone therapy originally, will now investigate the possible cardiovascular risk profile based on the above two studies.8 The FDA doesn’t suggest stopping medication if you are taking it presently, but it should be monitored closely. The agency, in the meantime, has issued an alert to doctors about the potential dangerous side effects of androgen replacement therapy. The FDA says that the use of testosterone therapy is for those with low levels and other medical issues, such as hypogonadism from either primary or secondary causes.

Obesity and weight loss

Not surprisingly, obesity is an important factor in testosterone levels. In a study that involved 900 men with metabolic syndrome — borderline or increased cholesterol levels, sugar levels and a waist circumference greater than 40 inches — those who lost weight were 50 percent less likely to develop testosterone deficiencies. Those who participated in lifestyle modification had a highly statistically significant 15 percent increase in testosterone.9 Also, when men increased their physical activity and made dietary changes, there was an almost 50 percent risk reduction one year out, compared to their baseline at the start of the trial.

Interestingly, metformin had no effect in preventing lower testosterone levels in patients with abnormal sugar levels, but lifestyle modifications did. These patients were relatively similar to the average American biometrics with prediabetes: HbA1c of 6 percent and glucose of 108 mg/dL; a mean of 42-inch waists; and a BMI that was obese at 32 kg/m2. The mean age was between 53 and 54.

If there is one thing that you get from this article, I hope it’s that testosterone is not something to be taken lightly. You can improve testosterone levels if you’re overweight by losing fat pounds. If you think you have symptoms and you might need testosterone, talk to your doctor about getting a blood test before you do anything. It may be preferable to try alternate medications that improve erections such as sildenafil and tadalafil.

References:

1 J Clin Endocrinol Metab. 2001 Feb;86(2):724. 2 J Clin Endocrinol Metab. Online 2014; Jan 1. 3 JAMA Intern Med. 2013 Aug 12;173(15):1465-6. 4 J Clin Endocrinol Metab. 2000 Aug;85(8):2839. 5 UpToDate.com. 6 PLoS One. 2014 Jan 29; 9(1):e85805. 7 JAMA. 2013;310:1829-1836. 8 FDA.gov. 9 ENDO 2012; Abstract OR28-3.

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.

The brain has to be the most important and complex organ, yet what we know about the brain is inverse to its prominence. In other words, our knowledge only scratches the surface. While other organs can be transplanted readily, it is the one organ that can’t, at least not yet.

The brain also has something called the blood-brain barrier. This is an added layer of small, densely packed cells, or capillaries, that filter what substances from the blood they allow to pass through from the rest of the body (1). This is good, since it protects the brain from foreign substances; however, on the downside, it also makes it harder to treat, because many drugs and procedures have difficulty penetrating the blood-brain barrier.

Unfortunately, there are many things that negatively impact the brain, including certain drugs, head injuries and lifestyle choices. There are also numerous disorders and diseases that affect the brain, including neurological (dementia, Parkinson’s, stroke); infection (meningitis); rheumatologic (lupus and rheumatoid arthritis); cancer (primary and secondary tumors); psychiatric mood disorders (depression, anxiety, schizophrenia); diabetes; and heart disease.

These varied diseases tend to have three signs and symptoms in common: they either cause an alteration in mental status; cognitive decline, weakness or change in mood; or a combination of these.

Probably our greatest fear regarding the brain is cognitive decline. We have to ask ourselves if we are predestined to this decline, either because of the aging process alone or because of a family history, or if there is a third option, a way to alter this course. Dementia, whether mild or full-blown Alzheimer’s, is cruel; it robs us of functioning. We should be concerned about Alzheimer’s because 5.2 million Americans have the disease, and it is on the rise, especially since the population is aging (2).

Fortunately, there are several studies that show we may be able to choose the third option and prevent cognitive decline by altering modifiable risk factors. They involve rather simple lifestyle changes: sleep and exercise and possibly omega-3s. Let’s look at the evidence.

The impact of clutter

The lack of control over our mental capabilities as we age is what frightens us the most since we see friends, colleagues and relatives negatively affected by it. Those who are in their 20s seem to be much sharper and quicker. But are they really?

In a recent study, German researchers found that educated older people tend to have a larger mental database of words and phrases to pull from since they have been around longer and have more experience (3).  When this is factored into the equation, the difference in terms of age-related cognitive decline becomes negligible.

This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something.

We may need a reboot just like a computer. This may be possible through sleep and exercise and omega-3s.

Sleep

I have heard people argue that sleep gets in the way of life. Why should we have to dedicate 33% of our lives to sleep? There are several good reasons. One involves clearing the mind, and other involves improving our economic outlook.

For the former, a recent study shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (4). When we have excessive plaque buildup in brain, it may be a sign of Alzheimer’s. This study was done in mice. When mice were sleeping, the interstitial space (the space between brain gyri, or structures) would increase by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough because cerebrospinal fluid could reach much further into the spaces. When the mice were anesthetized, a similar effect was seen as with sleeping. Interestingly, the follow-up study may be done in collaboration with Helene Benveniste, M.D., an anesthesiologist at Stony Brook University Hospital.

In the second study, done in Australia, results showed that sleep deprivation may have been responsible for an almost 1 percent decline in gross domestic product for the country (5). The reason is obvious: people are not as productive at work when they don’t get enough sleep. Their attitude tends to be more irritable, and concentration may be affected. We may be able to turn on and off sleepiness on an acute, or short-term, basis, depending on the environment, but it’s not as if we can do this continually.

According to the Centers for Disease Control, 4 percent of Americans have fallen asleep in the past month behind the wheel of a car (6). I hope this hammers home the importance of sleep.

Exercise

How can I exercise, when I can’t even get enough sleep? Well there is a study that just may inspire you to exercise.

In the study, which involved rats, those that were not allowed to exercise were found to have rewired neurons in the area of their medulla, the part of the brain involved in breathing and other involuntary activities. There was more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (7). In those rats that were allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart.

This is intriguing, since we used to think that our brain’s plasticity, or ability to grow and connect neurons, was finite and stopped after adolescence. This study’s implication is that a lack of exercise causes unwanted new connections. Of course, these results were done in rats and need to be studied in humans before we can make any definitive suggestions.

Omega-3 fatty acids

In the Women’s Health Initiative Memory Study Magnetic Resonance Imaging Study, results showed that those postmenopausal women who were in the highest quartile of omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (8). The hippocampus is involved in memory and cognitive function.

Specifically, the researchers looked at the level of omega-3 fatty acids, called eicosapentaenoic acid and docosahexaenoic acid, in red blood cell membranes. The source of the omega-3 fatty acids could either have been from fish or supplementation. This was not delineated. The researchers suggest eating fish high in these substances, such as salmon and sardines, since it may not even be the omega-3s that are playing a role, but some other substances in the fish.

It’s never too late to improve brain function. You can still be sharp at a ripe old age. Although we have a lot to learn about the functioning of the brain, we know that there are relatively simple ways we can positively influence it.

References: (1) medicinenet.com. (2) alz.org. (3) Top Cogn Sci. 2014 Jan.;6:5-42. (4) Science. 2013 Oct. 18;342:373-377. (5) Sleep. 2006 Mar.;29:299-305. (6) cdc.gov. (7)J Comp Neurol. 2014 Feb. 15;522:499-513. (8) Neurology. 2014;82:435-442.

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 and/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; they include thyroid stimulating hormone, 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 are 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 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 antibodies and antithyroglobulin antibodies.

Synopsis

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. Does subclinical hypothyroidism negatively impact cholesterol? There are studies that suggest this. 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 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 (FDA.gov). They could put a patients in a hyperthyroid state and worse, have 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 (10). 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, may exacerbate hypothyroidism. In one animal study, results suggested that very high intake of these vegetables does reduce thyroid functioning (11). This study was done over 30 years ago, and it has not been had 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 (12). 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, which is much needed.

There are two take-home points: try to avoid soy products and don’t think that supplements that claim to be thyroid support are good for you or harmless because they are over the counter and “natural.” In my experience, an anti-inflammatory diet helps improve quality of life issues, especially fatigue and weight, 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) Thyroid. 2008;18:293-301. (11) Crit Rev Food Sci Nutr. 1983;18:123-201. (12) 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 medicalcompassmd.com and/or consult your personal physician.

Gluten has been gaining in notoriety over the last several years. When we hear someone mention a gluten-free diet, several things tend to come to mind. One may be that this is a healthy diet. Along the same lines, we may think gluten is bad for us. However, gluten-free is not necessarily synonymous with healthy. There are many beneficial products containing gluten.

We might think that gluten-free diets are a fad, like low-fat or low-carb diets. Still, we keep hearing how more people feel better without gluten. Could this be a placebo effect? What is myth and what is reality in terms of gluten? In this article I will try to distill what we know about gluten and gluten-free diets, who may benefit and who may not.

But first, what is gluten? Most people I ask don’t know the answer, which is OK; it is part of the reason I am writing the article. Gluten is a plant protein found mainly in wheat, rye and barley.

Now to answer the question of whether going gluten-free is a fad. The answer is resounding “No,” since we know that patients who suffer from celiac disease, an autoimmune disease, benefit tremendously when gluten is removed.(1) In fact, it is the main treatment.

But what about people who don’t have celiac disease? There seems to be a spectrum of physiological reaction to gluten, from intolerance to gluten (sensitivity) to gluten tolerance (insensitivity). Obviously, celiac disease is the extreme of intolerance, but even these patients may be asymptomatic. Then, there is nonceliac gluten sensitivity, referring to those in the middle portion of the spectrum.(2) The prevalence of NCGS is half that of celiac disease, according to the NHANES data from 2009-2010.(3) However, many disagree with this assessment, indicating that it is much more prevalent and that its incidence is likely to rise.(4) The term was not even coined until 2011.

What is the difference between full-blown celiac disease and gluten sensitivity? They both may have intestinal symptoms, such as bloating, gas, cramping and diarrhea, as well as extraintestinal (outside the gut) symptoms, including gait ataxia (gait disturbance), malaise, fatigue and attention deficit disorder.(5) Surprisingly, they both may have the same results with serological (blood) tests, which may be positive or negative. The first line of testing includes antigliadin antibodies and tissue transglutaminase. These measure a reaction to gluten; however, they don’t have to be positive to have reaction to gluten. HLA–DQ phenotype testing is the second line of testing and tends to be more specific for celiac disease.

What is unique to celiac disease is a histological change in the small intestine, with atrophy of the villi (small fingerlike projections) contributing to gut permeability, what might be called “leaky gut.” Biopsy of the small intestine is the most definitive way to diagnose celiac disease.

Though the research has mainly focused on celiac disease, there is some evidence that shows NCGS has potential validity, especially in irritable bowel syndrome.

Before we look at the studies, what does it mean when a food says it’s “gluten-free”? Well, the FDA has recently weighed in by passing regulation that requires all gluten-free foods to have no more than 20 parts per million of gluten.(6) The agency has given food manufacturers a year to comply with the new standards. Now, let’s look at the evidence.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a nebulous disease diagnosed through exclusion, and the treatments are not obvious. That is why the results from a randomized controlled trial, the gold standard of studies, showing that a gluten-free diet significantly improved symptoms in IBS patients, is so important.(7) Patients were given a muffin and bread on a daily basis.

Of course, one group was given gluten-free products and the other given products with gluten, though the texture and taste were identical. In six weeks, many of those who were gluten-free saw the pain associated with bloating and gas mostly resolve; significant improvement in stool composition, such that they were not suffering from diarrhea; and their fatigue diminished. In fact, in one week, those in the gluten group were in substantially more discomfort than those in the gluten-free group. There were 34 patients involved in this study.

As part of a well-written March 4, 2013 editorial in Medscape, by David Johnson, M.D., a professor of gastroenterology at Eastern Virginia Medical School, he questions whether this beneficial effect from the IBS trial was due to gluten withdrawal or to withdrawal of fermentable sugars because of the elimination of some grains, themselves.(8) In other words, gluten may be just one part of the picture. He believes that nonceliac gluten sensitivity is a valid concern.

Autism

Autism is a very difficult disease to quantify, diagnose and treat. Some have suggested gluten may play a role. Unfortunately, in a study with children who had autism spectrum disorder and who were undergoing intensive behavioral therapy, removing both gluten and casein, a protein found in dairy, had no positive impact on activity or sleep patterns.(9) These results were disappointing. However, this was a very small study involving 22 preschool children. Removing gluten may not be a panacea for all ailments.

Antibiotics

The microbiome in the gut may play a pivotal role as to whether a person develops celiac disease. In an observational study using data from the Swedish Prescribed Drug Register, results indicate that those who were given antibiotics within the last year had a 40 percent greater chance of developing celiac disease and a 90 percent greater risk of developing inflammation in the gut.(10) The researchers believe that this has to do with dysbyosis, a misbalance in the microbiota, or flora, of the gastrointestinal tract. It is interesting that celiac disease may be propagated by change in bacteria in the gut from the use of antibiotics.

Not everyone will benefit from a gluten-free diet. In fact, most of us will not. Ultimately, people who may benefit from this type of diet are those patients who have celiac disease and those who have symptomatic gluten sensitivity. Also patients who have positive serological tests, including tissue transglutaminase or antigliadin antibodies are good candidates for gluten-free diets.

There is a downside to a gluten-free diet: potential development of macronutrient and micronutrient deficiencies. Therefore, it would be wise to ask your doctor before starting gluten withdrawal. The research in patients with gluten sensitivity is relatively recent, and most gluten research has to do with celiac disease. Hopefully, we will see intriguing studies in the near future, since gluten-free products have grown to a $4 billion industry that the FDA now has begun to regulate.

References:

(1) Am J Gastroenterol. 2013;108:656-676. (2) Gut 2013;62:43–52. (3) Scand J Gastroenterol. (4) Neurogastroenterol Motil. 2013 Nov;25(11):864-71. (5) medscape.com. (6) fda.gov. (7) Am J Gastroenterol. 2011; 106(3):508-14. (8) medscape.com. (9) 9th annual AIM for Autism Research 2010; abstract 140.007. (10) BMC Gastroenterol. 2013:13(109).

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.

Atrial fibrillation is the most common arrhythmia, an abnormal or irregular heartbeat, found in the U.S. Unfortunately, it is very complicated to treat. Though there are several options, including medications and invasive procedures, it mostly boils down to symptomatic treatment, rather than treating or reversing underlying causes.

What is AFib? It is an electrical malfunction that affects the atria, the two upper chambers of the heart, causing them to beat “irregularly irregular,” or with no set pattern affecting the rhythm and potentially causing a rapid rate. The result of this may be insufficient blood supply throughout the body.

Complications that may occur can be severely debilitating, such as stroke or even death. Its prevalence is expected to more than double in the next 16 years (1). Risk factors include age (the older we get, the higher the probability), obesity, high blood pressure, premature atrial contractions and diabetes.

AFib is not always symptomatic; however, when it is symptoms include shortness of breath, chest discomfort, light-headedness, fatigue and confusion. This arrhythmia can be diagnosed by electrocardiogram, but more likely with a 24-hour halter monitor. The difficulty in diagnosing AFib sometimes is because it can be intermittent.

There may be a better way to diagnose AFib. In a recent study, the Zio patch, worn for 14 days, was more likely to show arrhythmia than a 24-hour halter monitor (2). The Zio patch is a waterproof adhesive patch on the chest, worn like a Band-Aid, with one ECG lead.  While 50 percent of patients found the halter monitor to be unobtrusive, almost all patients found the Zio patch comfortable.

There are two main types of AFib, paroxysmal and persistent. Paroxysmal is acute, or sudden, and lasts for less than seven days, usually less than 24 hours. It tends to occur with greater frequency over time, but comes and goes. Persistent AFib is when a patient has AFib that continues past seven days (3). AFib is a progressive disease, meaning it only gets worse especially without treatment.

Medications are meant to treat either the rate or rhythm or prevent strokes from occurring. Medications that treat rate include beta blockers, like metoprolol, and calcium channel blockers, such as diltiazem (Cardizem). Examples of medications that treat rhythm are amiodarone and sotalol. Then there are anticoagulants that are meant to prevent stroke, such as warfarin and some newer medications, dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). The newer anticoagulants are easier to administer, but may have higher bleeding risks in some circumstances with no antidote.

There is also an invasive procedure, ablation, that requires threading a catheter through an artery, usually the femoral artery located in the groin, to reach the heart. In one type of ablation, the inappropriate nodes firing in the walls of the atria are ablated, or destroyed, using radiofrequency. This procedure causes scarring of the tissue in the atria. When successful, patients may no longer need medication. Let’s look at the evidence.

Premature atrial contractions

Premature atrial contractions, abnormal extra beats that occur in the atrium, may be a predictor of atrial fibrillation. In a recent study, PACs alone, when compared to the Framingham AF risk algorithm (a conglomeration of risk factors that excludes PACs) resulted in higher risk of AFib (4). When there were greater than 32 abnormal beats/hour, there was a significantly greater risk of AFib after 15 years of PACs. When taken together, PACs and the Framingham model were able to predict AFib risk better at 10 years out as well. Also, overall when the number of PACs doubled in patients, there was a 17 percent increased risk of AFib.

The role of obesity

There is good news and bad news with obesity in regards to AFib. Let’s first talk about the bad news. In studies, those who are obese are at significantly increased risk. In the Framingham Heart Study, the risk of developing AFib was 52 percent greater in men who were obese and 46 percent greater in women who were obese when compared to those of normal weight (5). Obesity was a BMI >30 kg/m2, and normal weight was a BMI <25 kg/m2. There were over 5,000 participants in this study with a follow-up of 13 years.

The Danish Diet, Cancer and Health Study reinforces these results by showing that obese men were at a greater than twofold increased risk of developing AFib, and obese women were at a twofold increased risk (6).

Now the good news: weight loss may help reduce the frequency of AFib episodes. That’s right, weight loss could be a simple treatment for this very dangerous arrhythmia. In a recent randomized controlled trial, the gold standard of studies, those in the intervention group lost significantly more weight, 14 kg (32 pounds) versus 3.6 kg (eight pounds), and saw a significant reduction in atrial fibrillation severity score compared to those in the control group (7). There were 150 patients involved in the study.

AFSS includes duration, severity and frequency of atrial fibrillation. All three components in the AFSS were reduced in the intervention group compared to the control group. There was a 692-minute decrease in the time spent in AFib over 12 months in the intervention arm, whereas there was 419-minute increase in the time in AFib in the control group. These results are potentially very powerful; this is the first study to demonstrate that managing risk factors may actually help manage the disease.

Caffeine

According to a recent meta-analysis (a group of six population-based studies) done in China, caffeine does not increase, and may even decrease, the risk of AFib (8). The study did not reach statistical significance. The authors surmised that drinking coffee on a regular basis may be beneficial because caffeine has antifibrosis properties. Fibrosis is the occurrence of excess fibrous tissue, in this case, in the atria, which most likely have deleterious effects. Atrial fibrosis could be a preliminary contributing step to AFib. Since these were population-based studies, only an association can be made with this discovery, rather than a hard and fast link. Still this is a surprising result.

However, in those who already have AFib, it seems that caffeine may exacerbate the frequency of symptomatic occurrences, at least anecdotally. With my patients, when we reduce or discontinue substances that have caffeine, such as coffee, tea and chocolate, the number of episodes of AFib seems to decline. I have also heard similar stories from my colleagues and their patients. So think twice before running out and getting a cup of caffeinated coffee if you have AFib.  What we really need are RCT studies done in patients with AFib, comparing people who consume caffeine regularly to those who have decreased or discontinued the substance.

The bottom line is this: if there were ever a reason needed for obese patients to lose weight, treating atrial fibrillation should be on the top of the list, especially since it is such a dangerous disease with potentially severe complications.

References:

(1) Am J Cardiol. 2013 Oct. 15;112:1142-1147. (2) Am J Med. 2014 Jan.;127:95.e11-7. (3) Uptodate.com. (4) Ann Intern Med. 2013;159:721-728. (5) JAMA. 2004;292:2471-2477. (6) Am J Med. 2005;118:489-495. (7) JAMA. 2013;310:2050-2060. (8) Canadian J Cardiol online. 2014 Jan. 6.

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 and/or consult your personal physician.