From left, Frank Recco, CFO Recco Home Care; Nancy Geiger, director, Gurwin Home Care Agency; Claudia Hammar, president NYS Association of Health Care Providers (NYSHCP); and Taryn Birkmire, executive director of Recco Home Care Photo courtesy of Gurwin Home Care Agency
Nancy Geiger, director of the Gurwin Home Care Agency, recently accepted the Norma Recco Advocate of the Year Award from the Long Island Chapter of the New York State Association of Health Care Providers (NYSAHCP) for her outstanding contributions to public advocacy to advance home and community-based care.
The award was first presented in 2011 to honor the memory of Norma Recco, a tireless advocate who advanced HCP from a local interest group to a statewide association, and who was the governor’s appointee to the New York State Home Care Council from 1987 to 1997.
Currently the vice president of the Long Island Chapter of the NYSAHCP, Geiger has specialized in the home care agency field for more than 30 years. She joined Gurwin as director of the Gurwin Home Care Agency in 2007. Under her leadership, the Gurwin agency provides home health aides and companions for Long Islanders who are in need of compassionate care and support.
“Nancy’s empathy for people is evident, whether she is advocating for her employees or her patients,” said Stuart B. Almer, president and CEO of the Gurwin Family of Healthcare Services. “She is committed to helping to get home care services to those who need them, and we are fortunate to have her leading our Gurwin Home Care Agency.”
Taryn Birkmire, executive director of Recco Home Care, presented Geiger with the award, applauding her for her years in the home care field, her work for the past six years for the chapter and her continued efforts in reaching out to legislators as well as her participation in advocacy events in Albany.
“I am truly humbled to receive this award and be recognized in the name of Norma Recco,” said Geiger. “Norma was a true pioneer in the home care industry, and she overcame many obstacles back in the early days in the field. Unfortunately, our challenges have become even greater in recent years. Home care plays an important and vital role in the lives of many in our communities, and I am honored to be able to fight for people to continue to receive the services they need to keep them living safely at home.”
Blood pressure readings taken at night may be the most accurate.
Stock photo
A simple technique can help indentify cardiovascular risk
By David Dunaief, M.D.
Dr. David Dunaief
Hypertension affects approximately one-third of Americans, according to the latest statistics from the Centers for Disease Control and Prevention, and only about half have it controlled (1). What could we possibly learn about blood pressure that we have not heard already? Studies teach us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. Let’s look at the evidence.
Technique
When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms because there may be significant benefit from this.
An analysis of the Framingham Heart Study and Offspring Study showed that when blood pressure was taken in both arms, when there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease (2).
This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.
So, the next time you go to the doctor’s office, you might ask them to take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.
Timing
When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (3). This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.
With patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. At least one of the readings should be taken before antihypertensive medications are taken, since these will alter the readings.
Salt impact
There has always been a debate about whether salt plays a role in high blood pressure and heart disease. The latest installment is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (4). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.
One potential study weakness was that physical activity was not taken into account. However, this study’s strength was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods we least suspect, such as breads, pastas and cheeses.
Age-related macular degeneration
When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (5). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics and angiotensin receptor blockers.
However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.
Fall risk
One study shows that blood pressure medications significantly increase fall risk in the elderly (6). Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.
Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.
In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.
References:
(1) CDC.gov/blood pressure. (2) Am J Med. 2014 Mar;127(3):209-215. (3) J Am Soc Hypertens 2014;8:e59. (4) BMJ Open 2014;4:e004549. (5) Ophthalmology online April 30, 2014. (6) JAMA Intern Med. 2014;174(4):588-595.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
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If you’re missing out on shut-eye, your body will soon show the signs. Stock photo
Getting enough sleep helps clear brain clutter
By David Dunaief, M.D.
Dr. David Dunaief
The brain is the most complex organ, yet what we know about the brain is inverse to its importance.
We do know that certain drugs, head injuries and lifestyle choices negatively impact the brain. There are also numerous disorders and diseases that affect the brain, including neurological (dementia, Parkinson’s, stroke), infectious (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 altered mental status, physical weakness or change in mood — or a combination of these.
Probably our greatest fear regarding the brain is cognitive decline. Dementia, whether mild or full-blown Alzheimer’s, is cruel; it robs us of functioning.
Fortunately, there are several studies that show we may be able to prevent cognitive decline by altering modifiable risk factors. They involve rather simple lifestyle changes: sleep, 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 most. Those who are in their 20s seem to be much sharper and quicker. But are they really?
In a 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 (1). 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, exercise and omega-3s.
The importance of sleep
Why should we dedicate 33 percent of our lives to sleep? There are several good reasons. One involves clearing the mind, and another involves improving our economic outlook.
For the former, a study shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (2). When we have excessive plaque buildup in the 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) increased 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 farther into the spaces. A similar effect was seen when the mice were anesthetized.
In another 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 (3). The reason is obvious: People are not as productive at work when they don’t get enough sleep. They tend to be more irritable, and concentration may be affected. We may be able to turn on and off sleepiness on short-term basis, depending on the environment, but we can’t do this continually.
According to the Centers for Disease Control and Prevention, 4 percent of Americans report having fallen asleep in the past month behind the wheel of a car (4). I hope this hammers home the importance of sleep.
Time to 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 (5). In rats 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 of 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 (6). The hippocampus is involved in memory and cognitive function.
Specifically, the researchers looked at the levels of 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. 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.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
The decision to take a statin is an important one. Stock photo
Fatigue and cataracts are downsides
By David Dunaief, M.D.
Dr. David Dunaief
Statins are one of the most commonly prescribed medications in the United States. Yet, some in the medical community believe that more patients should be on this class of drugs while others think it is one of the most overprescribed medications. Suffice to say, this is one of the most polarizing topics in medicine — probably rightfully so.
The debate is over primary prevention with statins. Primary prevention is treating people with high cholesterol and/or inflammation who may be at risk for a cardiovascular event, such as a stroke or heart attack.
Fortunately, most physicians would agree that statins have their place in secondary prevention — treating patients who have had a stroke or heart attack already or have coronary artery disease.
We are going to look at benefits and risks for the patient population that could take statins for primary prevention. On one side, we have the statin as Rocky Balboa, coming out to fight off cancer risk, both overall and esophageal, as well as improving quality of life and glaucoma. On the other, we have the statin as Evel Knievel, demonstrating that reckless heroics don’t provide longevity, but they do increase diabetes risk, promote fatigue and increase cataracts. Let’s look at some of the evidence.
Effect on cancer
A study published in The New England Journal of Medicine involved 300,000 Danish participants and investigated 13 cancers. It showed that statin users may have a 15 percent decreased risk of death from cancer (1). This is exciting news.
However, there were major limitations with the study. First, the researchers did not control for smoking, which we know is a large contributor to cancer. Second, it was unknown which of the statin-using population might have received conventional cancer treatments, such as radiation and chemotherapy. Third, the dose of statins did not correlate to risk reduction. In fact, those who took 1 to 75 percent of prescribed statin levels showed more benefit in terms of cancer mortality risk than those who took more. We need a better-designed trial that is prospective (forward looking) to determine whether there really is an effect. I would say that Rocky Balboa came out of this fight pretty banged up.
Another study showed that statins may play a role in reducing the risk of esophageal cancer. This is important, since esophageal cancer, especially adenocarcinoma that develops from Barrett’s esophagus, is on the rise. The results showed a 28 percent risk reduction in this type of cancer. The authors of the study surmise that statins may have a protective effect. This was a meta-analysis of 13 observational studies (2).
Although there is an association, these results need to be confirmed with randomized controlled trials. Remember, aspirin has about the same 30 percent reduction in colorectal cancer, yet is not recommended solely for this use because of side effects.
Eye diseases: mixed results
In two common eye diseases, glaucoma and cataracts, statins have vastly different results. In one study, statins were shown to decrease the risk of glaucoma by 5 percent over one year and 9 percent over two years (3). It is encouraging that the longer the duration of statin use, the greater the positive effect on preventing glaucoma.
Statins also help to slow glaucoma progression in patients suspected of having early-stage disease at about the same rate. This was a retrospective (backward-looking or looking in the past) study analyzing statin use with patients at risk for open-angle glaucoma. There is a need for prospective (forward-looking) studies. With cataracts, it is a completely different story. Statins increase the risk of cataracts by over 50 percent, as shown in the Waterloo Eye Study (4). Statins exacerbate the risk of cataracts in an already high-risk group: diabetes patients.
Quality of life and longevity: a mixed bag
In a meta-analysis involving 11 randomized controlled trials, considered the gold standard of studies, statins did not reduce the risk of all-cause mortality in moderate to high-risk primary prevention participants (5). This study analysis involved over 65,000 participants with high cholesterol and at significant risk for heart disease.
However, in this same study, participants at high risk of coronary heart disease saw a substantial improvement in their quality of life with statins. In other words, the risk of a nonfatal heart attack was reduced by more than half and nonfatal strokes by almost half, avoiding the potentially disabling effects of these cardiovascular events.
Fatigue effect
Some of my patients who are on statins ask if statins can cause fatigue. A randomized controlled trial published in the Archives of Internal Medicine reinforces the idea that statins increase the possibility of fatigue (6).
Women, especially, complained of lower energy levels, both overall and on exertion, when they were blindly assigned to a statin-taking group. The trial was composed of three groups: two that took statins, simvastatin 20 mg and pravastatin 40 mg; and a placebo group. The participants were at least 20 years old and had LDL (bad) cholesterol of 115 to 190 mg/dl, with less than 100 mg/dl considered ideal.
In conclusion, some individuals who are at high risk for cardiovascular disease may need a statin, but with the evidence presented, it is more likely that statins are overprescribed in primary prevention. Evidence of the best results points to lifestyle modification, with or without statins, and all patients with elevated LDL (bad) cholesterol should make changes that include a nutrient-dense diet and a reduction in fat intake, as well as exercise.
References:
(1) N Engl J Med 2012;367:1792-1802. (2) Clin Gastroenterol Hepatol. 2013 Jun; 11(6):620–629. (3) Ophthalmology 2012;119(10):2074-2081. (4) Optom Vis Sci 2012;89:1165-1171. (5) Arch Intern Med 2010;170(12):1024-1031. (6) Arch Intern Med 2012;172(15):1180-1182.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
What if, instead of defeating or removing enemy soldiers from the battlefield, a leader could convince them to join the fight, sending them back out to defeat the side they previously supported? That’s the question Giulia Biffi, a postdoctoral researcher at Cold Spring Harbor Laboratory, is asking about a particular type of cells, called fibroblasts, that are involved in pancreatic cancer.
Fibroblasts activated by cancer cells secrete a matrix that surrounds cancer cells and makes up about 90 percent of pancreatic tumors.
Responding to a molecule called IL-1, an inflammatory potential tumor-promoting fibroblast may enhance the opportunity for cancer to grow and spread. Another type of fibroblast responds to TGF-beta, which potentially enables them to restrain tumors.
Researchers had suggested that the inflammatory fibroblasts are tumor promoting, while the myofibroblasts are tumor defeating, although at this point, that still hasn’t been confirmed experimentally.
Researchers knew TGF-beta was important in biology, but they didn’t know that it was involved in preventing the activation of an inflammatory tumor-promoting version.
Biffi, however, recently found that IL-1 promotes the formation of inflammatory fibroblasts. She believes these fibroblast promote tumor growth and create an immunosuppressive environment.
In an article published in the journal Cancer Discovery, Biffi showed that it’s “not only possible to delete the population, but it’s also possible to convert [the fibroblasts] into the other type, which could be more beneficial than just getting rid of the tumor-promoting cells,” she said.
Biffi works in Director Dave Tuveson’s CSHL Cancer Center laboratory, which is approaching pancreatic cancer from numerous perspectives.
Her doctoral adviser, Sir Shankar Balasubramanian, the Herchel Smith Professor of Medicinal Chemistry at the University of Cambridge, suggested that the work she did in Tuveson’s lab is an extension of her successful research in England.
“It is evident that [Biffi] is continuing to make penetrating and important advances with a deep and sophisticated approach to research,” Balasubramanian explained in an email. “She is without a doubt a scientist to watch out for in the future.”
To be sure, at this stage, Biffi has performed her studies on a mouse model of the disease and she and others studying fibroblasts and the tumor microenvironment that dictates specific molecular pathways have considerable work to do to extend this research to human treatment.
She doesn’t have similar information from human patients, but the mouse models show that targeting some subsets of fibroblasts impairs cancer growth.
“One of the goals we have is trying to be able to better classify the stroma from pancreatic cancer in humans,” Biffi said. The stroma is mixed in with the cancer cells, all around and in between clusters of cells.
The results with mice, however, suggest that approaching cancer by understanding the molecular signals from fibroblasts could offer a promising additional resource to a future treatment. In a 10-day study of mice using a specific inhibitor involved in the pathway of inflammatory fibroblasts, Biffi saw a reduction in tumor growth.
If Biffi can figure out a way to affect the signals produced by fibroblasts, she might be able to make the stroma and the cancer cells more accessible to drugs. One potential reason other drugs failed in mouse models is that there’s increased collagen, which is a barrier to drug delivery. Drugs that might have failed in earlier clinical efforts could be reevaluated in combination with other treatments, Biffi suggested, adding if scientists can manage to target the inflammatory path, they might mitigate some of this effect.
A native of Bergamo, Italy, which is near Milan, Biffi earned her doctorate at the Cancer Research UK Cambridge Institute. Biffi lives on a Cold Spring Harbor property which is five minutes from the lab.
When she was young, Biffi wanted to be a vet. In high school, she was fascinated by the study of animal behavior and considered Dian Fossey from “Gorillas in the Mist” an inspiration. When she’s not working in the lab, she enjoys the opportunity to see Broadway shows and to hike around a trail on the Cold Spring Harbor campus.
Biffi started working on fibroblasts three years ago in Tuveson’s lab. “I really wanted to understand how fibroblasts become one population or the other when they were starting from the same cell type,” she said. “If they have different functions, I wanted to target them selectively to understand their role in pancreatic cancer to see if one might have a tumor restraining role.”
A postdoctoral researcher for over four years, Biffi is starting to look for the next step in her career and hopes to have her own lab by the end of 2019 or the beginning of 2020.
When she was transitioning from her doctoral to a postdoctoral job, she was looking for someone who shared her idealistic view about curing cancer. Several other researchers in Cambridge suggested that she’d find a welcome research setting in Tuveson’s lab. Tuveson was “popular” among principal investigators in her institute, Biffi said. “I wanted to work on a hard cancer to treat and I wanted to work with [Tuveson].”
Biffi hopes that targeting the inflammatory pro-tumorigenic fibroblasts and reprogramming them to the potentially tumor-restraining population may become a part of a pancreatic cancer treatment.
She remains optimistic that she and others will make a difference. “This can be a frustrating job,” she said. “If you didn’t have hope you can change things, you wouldn’t do it. “I’m optimistic.”
Biffi points to the hard work that led to treatments for the flu and for AIDS. “Years back, both diseases were lethal and now therapeutic advances made them manageable,” she explained in an email. “That is where I want to go with pancreatic cancer.”
Vitamin D is one the most widely publicized and important supplements. We get vitamin D from the sun, food and supplements. With our days rapidly shortening here in the Northeast, let’s explore what we know about vitamin D supplementation.
There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of the treatment paradigm. However, many questions remain. As more data come in, their meaning for vitamin D becomes murkier. For instance, is the sun the best source of vitamin D?
At the 70th annual American Academy of Dermatology meeting, Dr. Richard Gallo, who was involved with the Institute of Medicine recommendations, spoke about how, in most geographic locations, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water fatty fish, such as salmon, sardines and tuna.
We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular and autoimmune diseases and cancer.
There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends more than 20 ng/dl, and The Endocrine Society recommends at least 30 ng/dl.
Cardiovascular mixed results
Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (1).
However, a small randomized controlled trial (RCT), the gold standard of studies, called the cardioprotective effects of vitamin D into question (2). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.
The vitamin D dose given to the treatment group was 2,500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study end points.
Long-awaited VITAL study results for cancer and cardiovascular events
Most trials relating to vitamin D are observational, which provides associations, but not links. However, results of the VITAL study, a large, five-year RCT looking at the effects of vitamin D and omega-3s on cardiovascular disease and cancer were just published this week (3). Study results were disappointing, finding that daily vitamin D3 supplementation at 2000 IUs did not reduce the incidence of cancers (prostate, breast or colorectal) or of major cardiovascular events.
Mortality decreased
In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: 9 percent reduction with vitamin D plus calcium and 7 percent with vitamin D alone.
One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.
Weight benefit
There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/dl, compared to those below this level, in the Study of Osteoporotic Fractures (4).
This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/dl in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.
USPSTF recommendations
The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (6). The supplement combination does not seem to reduce fractures, but does increase the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention. But as I mentioned previously, the recent VITAL study did not show any benefit for cancer prevention.
When to supplement?
It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it may play an integral role with many disorders. But it is also important not to raise the levels too high. The range that I tell my patients is between 30 and 55 ng/dl, depending on their circumstances — those who are healthy and those who have chronic diseases and what type of chronic diseases.
References:
(1) Circulation. 2008 Jan 29;117(4):503-511. (2) PLoS One. 2012;7(5):e36617. (3) NEJM. 2018 published online Nov. 10, 2018. (4) J Women’s Health (Larchmt). 2012 Jun 25. (5) J Clin Endocrinol Metabol. online May 17, 2012. (6) JAMA. 2018;319(15):1592-1599.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
Veterans struggling with their time served in the military now have the option of seeking peer support through a program at Island Christian Church in Port Jefferson. Stock photo
A Port Jefferson pastor has a message for veterans struggling with actions taken in their past: you are not alone.
Joining the armed services and venturing overseas, leaving one’s family, being tasked in some cases with taking a life, and in all cases being at least an indirect party to that reality, weighs heavy on a human being’s mind. To try to relieve some of that burden in an informal, judgment-free setting, Pastor Pete Jansson of Island Christian Church in Port Jefferson, in accordance with the Rev. Fred Miller of the Suffolk County American Legion, have established a program called Vet 2 Vet, a peer support group where those who have served and are suffering from “moral injury” can meet with someone who has been through the same as a means of healing.
“Post-traumatic stress is the result of a near-death experience or witnessing a tragic event such as your fellow troops being blown up or killed,” Miller wrote on the subject. “Moral injury is mental injury caused by being forced to do or witness things against your moral values, such as the killing or harming [of] others, witnessing death, failing to prevent immoral acts of others, or giving or receiving orders from authority that are against one’s moral values.”
The program features military members, who have struggled with moral injury themselves previously but have reached a place of inner peace, that have been trained in how to help their fellow veterans deal with moral injury through a Department of Veterans Affairs program. The group meets on the third Tuesday of each month at Island Christian, first in roundtable group discussions, then pairing off in a “buddy system” format, according to Jansson. So far two meetings have been held and Jansson is hoping to get the word out to boost attendance.
“The bottom line is they’re believing a lie, and we’re trying to identify that lie and then replace it with truth and that’s where the challenge is,” he said of the idea that carrying out orders while in the military becomes a burden carried by veterans. “There’s this internal struggle that they have as they begin to recognize that they were there for a purpose and asked to perform this task — not asked but ordered — and that they didn’t actually violate a moral code.”
Jansson said the group is prepared to refer attendees for professional mental health services if needed, through the VA or otherwise, but that the idea of the program is to offer an alternative to those hesitant about reaching out for help. He explained why he wanted to be involved in such a program after meeting Miller, who has ties to the American Legion and has dedicated his post-pastoring life to helping veterans.
“I have a real passion for this village and a real desire to meet felt needs in people’s lives,” said Jansson. “We’ve done grief share classes for people that have gone through a tremendous loss. I personally lost my wife to cancer six years ago this month, and so I’ve been through the grief share.”
Those interested in being involved in the program, either in need of support or to help those seeking it, are instructed to contact Jansson at 631-473-9229 or Miller at 631-395-4646.
Regular exercise helps prevent or manage a wide range of health problems and concerns.
Stock photo
The real benefits of exercise
By David Dunaief, M.D.
Dr. David Dunaief
With holiday dinners right around the corner, what would be a better topic than exercise? To quell our guilt about Thanksgiving dinner indiscretions, many of us will resolve to exercise to burn off the calories from this seismic meal and the smaller, calorically dense aftershock meals, whether with a vigorous family football game or with a more modest walk.
Unfortunately, exercise without dietary changes may not actually help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance. Therefore, it may be more important to think about what you are eating than to succumb to the rationalization that you can eat with abandon during the holidays and work it off later.
Don’t give up on exercise just yet, though. There is very good news: Exercise does have beneficial effects on a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.
Let’s look at the evidence.
Weight loss attenuated
The well-known weight-loss paradigm in medicine is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, the results of a study say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.
However, more than two-thirds of the women (55) gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. Significant variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise — or, in other words, a moderately intense pace.
The good news is that the women were in better aerobic shape by the end of the study and that women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study. This was a preliminary study, so no definitive conclusions can be made.
Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials — the gold standard of studies — results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.
Weight maintenance
However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).
Chronic kidney disease
As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 14 percent of adults in the United States, according to the Centers for Disease Control and Prevention (7). The U.S. Preventive Services Task Force has indicated that there is insufficient evidence to treat asymptomatic CKD. In fact, the American College of Physicians has said that asymptomatic CKD, which includes stages 3a and 3b, or moderate disease levels, should not be screened for, since the treatment risks outweigh the benefits, and lead to false positive results and unnecessary treatments (8).
However, in a trial, results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3-5 (9). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to nonwalkers.
Walking had an impressive impact; results were based on a dose-response curve. In other words, the more frequently patients walked in the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.
Therefore, while it is important to enjoy the holidays, it is food choices, not exercise, that will have the greatest impact on our weight and body composition. However, exercise is extremely beneficial for preventing progression of chronic disorders, such as CKD.
So, by all means, exercise during the holidays, but also focus on more nutrient-dense foods. At a minimum, strike a balance rather than eating purely calorically dense foods. You won’t be able to exercise them away.
References:
(1) uptodate.com. (2) J Strength Cond Res. Online Oct. 28, 2014. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Ann Intern Med. online October 21, 2013. (9) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
Isabella Gordon, 15, organizes the nearly 300 pounds of hygiene products she collected for donation. Photo from Ali Gordon
Inspired by a leadership camp she attended over the summer, Comsewogue High School sophomore Isabella Gordon identified a problem in her community and took it upon herself to fix it. Before she knew it, her bedroom was piled high with feminine hygiene products set for donation.
Isabella, 15, said she had been interested in attending the Eleanor Roosevelt Girls Leadership Worldwide camp, a program offered by the Eleanor Roosevelt Center at Val-Kill in Hyde Park New York aimed at helping attendees gain confidence, develop a voice and unlock one’s leadership potential, ever since her older sister attended more than a decade ago. She went this past summer and met young women from around the world, and upon returning home, she was struck with an idea.
The teenager said she came across a video on YouTube that detailed the difficulty homeless women on their menstrual cycle have in obtaining hygiene products and wasted little time springing to action.
“I was interested and talked to my mom that night and was like, ‘Hey, I want to work on this,’” she said following a Comsewogue board of education meeting Nov. 5, where her mom Ali Gordon has served on the board for three terms. “So for the next week or so me and my sister were kind of just thinking up names for it and we ended up with ‘Hygiene for All,’ came up with a mission statement, because I felt so passionate about it.”
Isabella said she set up a Facebook page for her newly formed initiative and asked people to donate products for her cause by sending them to her home. Eventually her bedroom was piled with items in bins waiting to be distributed to those who needed them. Mineola-based nonprofit food bank Island Harvest organized a “stuff-a-bus” event Oct. 6 at Comsewogue’s homecoming football game, during which attendees of the game were encouraged to bring food items to be donated to those in need. Isabella and Hygiene for All provided the food bank with more than 100 boxes of feminine hygiene products, dozens of toothbrushes and tubes of toothpaste, shampoo and conditioner, and deodorants. In all the haul amassed nearly 300 pounds, according to Gordon.
“It was incredibly inspiring to have my 15-year-old come up with the idea,” the BOE member said. “Inspiring and very exciting. She didn’t need much assistance at all. She had a vision for this and really wanted to be able to help people and she’s done that and plans to continue to do that.”
Isabella said she hopes to one day turn the project into a charitable venture and is already interested in expanding it to more communities and school districts. She said she hopes to pursue a degree in medicine, at this point with her eye on one day becoming a midwife. Feminine hygiene products are among the most requested items for all food pantries, as many homeless and disadvantaged women are forced to choose between spending money on items like these and food, according to Food Bank for New York City, which holds an annual campaign calling for products for women.
“I feel very proud, especially of my community, so I’d say it went pretty well,” Isabella said.
To donate visit Hygiene for All’s Facebook page and send a private message to get the address.
Key lifestyle choices may reduce your risk significantly
By David Dunaief, M.D.
Dr. David Dunaief
Happy “Movember!” The Movember Foundation is in its 11th year of raising awareness and research money for men’s health issues (1). What better time to discuss prostate cancer prevention?
The best way to avoid prostate cancer is through lifestyle modifications, which means learning about both detrimental and beneficial approaches. There are a host of things that may increase your risk and others that may decrease your likelihood of prostate cancer. Your family history does not mean you can’t alter gene expression with the choices you make.
What may increase the risk of prostate cancer? Contributing factors include obesity, animal fat and supplements, such as vitamin E and selenium. Equally as important, factors that may reduce risk include vegetables, especially cruciferous, and tomato sauce or cooked tomatoes.
Vitamin E and selenium
In the SELECT trial, a randomized clinical trial (RCT), a dose of 400 mg of vitamin E actually increased the risk of prostate cancer by 17 percent (2). Though significant, this is not a tremendous clinical effect. It does show that vitamin E should not be used for prevention of prostate cancer. Interestingly, in this study, selenium may have helped to reduce the mortality risk in the selenium plus vitamin E arm, but selenium trended toward a slight increased risk when taken alone. Therefore, I would not recommend that men take selenium or vitamin E for prevention.
Obesity
Obesity showed conflicting results, prompting the study authors to analyze the results further. According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer, however increase risk of aggressive disease (3). Don’t think this means that obesity has protective effects. It’s quite the contrary. The authors attribute the lower incidence of nonaggressive prostate cancer to the possibility that it is more difficult to detect the disease in obese men, since larger prostates make biopsies less effective. What the results tell us is that those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.
Animal fat, red and processed meats
The risk of developing prostate cancer increases with age. Stock photo
It seems there is a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, a large observational study, those who consumed the highest amount of animal fat had a 63 percent increased risk, compared to those who consumed the least (4).
Here is the kicker: It was not just the percent increase that was important, but the fact that it was an increase in advanced or metastatic prostate cancer. Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you are going to eat red meat, I recommend decreased frequency, like lean meat once every two weeks or once a month.
In another large, prospective (forward-looking) observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (5).
Omega-3s paradox
When we think of omega-3 fatty acids or fish oil, we think “protective” or “beneficial.” However, these may increase the risk of prostate cancer, according to one epidemiological study (6). This study, called the Prostate Cancer Prevention Trial, involving a seven-year follow-up period, showed that docosahexaenoic acid (DHA), a form of omega-3 fatty acid, increased the risk of high-grade disease 2.5-fold. This finding was unexpected. If you choose to eat fish, salmon or sardines in water with no salt are among the best choices.
Lycopene – found in tomato sauce
Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown beneficial effects. This may be because, in order to release lycopene, the tomatoes need to be cooked (7). It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit.
In a prospective (forward-looking) study involving 47,365 men who were followed for 12 years, the risk of prostate cancer was reduced by 16 percent (8). The primary source of lycopene in this study was tomato sauce. When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.
In the Health Professionals Follow-up Study, the results were similar, with a 21 percent reduction in the risk of prostate cancer (9). Again, tomato sauce was the predominant food responsible for this effect. This was another large observational study with 47,894 participants. Although tomato sauce may be beneficial, many brands are loaded with salt. I recommend to patients that they either make their own sauce or purchase a sauce with no salt, such as one made by Eden Organics.
Vegetable effects
Vegetables, especially cruciferous vegetables, reduce the risk of prostate cancer significantly. In a case-control study (comparing those with and without disease), participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (10). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.
When it comes to preventing prostate cancer, lifestyle modification, including making dietary changes, can reduce your risk significantly.
References:
(1) www.movember.com. (2) JAMA. 2011; 306: 1549-1556. (3) Epidemiol Rev. 2007;29:88. (4) J Natl Cancer Inst. 1993;85(19):1571. (5) Am J Epidemiol. 2009;170(9):1165. (6) Am J Epidemiol. 2011 Jun 15;173(12):1429-1439. (7) Exp Biol Med (Maywood). 2002; 227:914-919. (8) J Natl Cancer Inst. 2002;94(5):391. (9) Exp Biol Med (Maywood). 2002; 227:852-859; Int. J. Cancer. 2007;121: 1571–1578. (10) J Natl Cancer Inst. 2000;92(1):61.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
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