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Increasing potassium may improve health outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Most Americans consume far too much sodium — an average of 3400 mg per day, which is well over the 2300 mg per day recommended upper limit for teens and adults (1). It’s become such an issue that the FDA is working with food manufacturers and restaurants to drive these numbers down (2).

If you don’t have hypertension, what difference does it make? Sodium can have a dramatic effect on your health, regardless of your blood pressure.

It’s hard to avoid, with sodium hiding even in foods that don’t taste salty, like bread products and salad dressings. Other foods with substantial amounts of sodium include cold cuts and cured meats, cheeses, poultry, soups, pasta, sauces and, of course, snack foods. Packaged foods and restaurant meals are where most of our consumption occurs.

In contrast, only about two percent of people consume enough potassium in their diets (3). According to the National Institutes of Health, target potassium intake is between 2600 mg and 3400 mg for adult women and men, respectively.

How are sodium and potassium related?

A high sodium-to-potassium ratio increases your cardiovascular disease risk by 46 percent, according to a 15-year study of more than 12,000 participants (4).

A more recent analysis of over 10,000 participants followed for almost nine years tested sodium and potassium excretion, a more reliable measure of intake, and found that higher sodium excretion, lower potassium excretion, and a higher sodium-to-potassium ratio were all associated with a higher cardiovascular risk (5). Each daily incremental increase of 1000 mg in sodium excretion was associated with an 18 percent increase in cardiovascular risk.

To improve your overall health, you might need to shift your sodium-to-potassium balance so that you consume more potassium and less sodium. And if you struggle with — or are at risk for — high blood pressure, this approach could help.

Why lower your sodium consumption?

Two studies illuminate the benefits of reducing sodium in high and normal blood pressure patients, ultimately preventing cardiovascular disease, including heart disease and stroke.

The first was a meta-analysis that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. It demonstrated that salt reduction from 9-to-12 grams per day to 5-to-6 grams per day had a dramatic effect. Blood pressure in both normotensive and hypertensive participants was reduced by a significant mean of −4.18 mm Hg systolic (top number) and −2.06 mm Hg diastolic (bottom number) (6).

When looking solely at hypertensive patients, the reduction was even greater, with a systolic blood pressure reduction of −5.39 mm Hg and a diastolic reduction of −2.82 mm Hg.

The researchers believe that the more we reduce salt intake, the greater the blood pressure reduction. The authors recommend further reduction to 3 grams per day as a long-term target and hypothesize that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

In the second study, a meta-analysis of 42 clinical trials including both adults and children, there was a similarly significant reduction in both systolic and diastolic blood pressures (7). Both demographics experienced a blood pressure reduction, although the effect was greater in adults. Interestingly, an increase in sodium caused a 24 percent increased risk of stroke incidence but, more importantly, a 63 percent increased risk of stroke mortality. The risk of mortality from heart disease increased by 32 percent alongside an increase in sodium.

Isn’t too little sodium a risk?

Some experts warn that sodium levels that are too low can be a problem. While this is true, it’s very rare, unless you have a health condition or take medication that depletes sodium. Since sodium is hiding everywhere, even if you don’t add salt to your food, you’re probably consuming more than the recommended amount of sodium.

Why focus on potassium consumption?

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (8). When high blood pressure patients consumed foods containing 3.5 to 4.7 grams of potassium, they experienced an impressive −7.16 mm Hg reduction in systolic blood pressure. Anything more than this amount of potassium did not provide additional benefit. Increased potassium intake also reduced stroke risk by 24 percent.

Blood pressure reduction was greater with increased potassium consumption than with sodium restriction, although this was not a head-to-head comparison. The good news is that it’s easy to increase your potassium intake; it’s found in many whole foods and is richest in fruits, vegetables, beans and legumes.

So, what’s the bottom line? Decrease your sodium intake and increase your potassium intake from foods to strike a better sodium-to-potassium balance. As you reduce your sodium intake, give yourself a brief period to adapt; it takes about six weeks to retrain your taste buds.

References:

(1) Dietary Reference Intakes for Sodium and Potassium. Washington (DC): National Academies Press (US); 2019 Mar. (2) fda.gov. (3) nih.gov. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) N Engl J Med 2022;386:252-263. (6) BMJ. 2013 Apr 3;346:f1325. (7) BMJ. 2013 Apr 3;346:f1326. (8) BMJ. 2013; 346:f1378.

Dr. David 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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Reducing dairy consumption can decrease inflammation

By David Dunaief, M.D.

Dr. David Dunaief

Osteoarthritis (OA) can disturb your mobility, mood, and sleep quality, making it difficult to perform daily activities, which can affect your quality of life. Most often, it affects the knees, hips and hands. Acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen, are common first-line medications to help treat arthritis pain. Unfortunately, they do have side effects, which become more pronounced with long-term use. 

While medications might relieve your immediate pain and inflammation symptoms, they don’t slow osteoarthritis’ progression. However, there are some approaches that can ease your pain without reaching for medications. Some might even help slow your OA’s progression.

The effect of losing weight on OA pain

Weight management is important to any OA pain management strategy. In a study of 112 obese patients, those who lost weight reported that their knee symptoms improved (1). The study authors also observed disease modification in this population, with a reduction in the loss of cartilage volume around the medial tibia.

The relationship was almost one-to-one; for every one percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the opposite occurred for study participants who gained weight. A reduction of tibial cartilage is often associated with the need for a knee replacement.

Does vitamin D help ease OA pain?

In a randomized controlled trial (RCT), vitamin D provided no OA symptom relief, nor any disease-modifying effects (2). The two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

In another study of 769 participants, ages 50-80, researchers found that low vitamin D levels – below 25 nmol/l led to increased OA knee pain over the five-year study period and hip pain over 2.4 years (3). The researchers postulate that supplementing vitamin D might reduce pain for those who are deficient, but that it will likely have no effect on others.

What about dairy?

With dairy, specifically milk, there is conflicting information. Some studies show benefits, while others show that it might contribute to the inflammation that makes osteoarthritis pain feel worse.

In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (4). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

The result curve was complicated, though. For those who drank fewer than three glasses a week up to 10 glasses a week, the progression of joint space narrowing slowed. However, for those who drank more than 10 glasses per week, there was less benefit. Men and those who consumed higher fat products, such as cheese or yogurt, saw no benefit.

However, the study had significant flaws. The 2100 patients were only asked about their milk intake at the study’s start and were asked to recall their weekly milk consumption for the previous 12 months – a challenging task.

In a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study researchers found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (5).

Is diet or exercise better for reducing osteoarthritis pain?

Diet and exercise together actually trumped the effects of diet or exercise alone in a well-designed, 18-month study (7). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant functional improvements and a 50 percent pain reduction, as well as inflammation reduction. This was compared to those who lost a lower percent of their body weight.

Researchers used biomarker IL-6 to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking “with alacrity” three times a week.

To reduce pain and possibly improve your OA, focus on lifestyle modifications. The best effects shown are with weight loss which is most easily achieved with a vegetable-rich diet and exercise. In terms of low-fat or nonfat milk, the results are controversial, at best. If you don’t eliminate dairy, stay on the low end of consumption, since it can increase inflammation.

References:

(1) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (2) JAMA. 2013;309:155-162. (3) Ann. Rheum. Dis. 2014;73:697–703. (4) Arthritis Care Res online. 2014 April 6. (5) J Rheumatol. 2017 Jul;44(7):1066-1070. (6) Nutrients. 2021 Feb 4;13(2):506. (7) JAMA. 2013;310:1263-1273.

Dr. David 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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Lowering cortisol levels can help manage weight

By David Dunaief, M.D.

Dr. David Dunaief

Losing or maintaining body weight is complex. Many things influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

While calorie intake is an important element of the equation, knowing a food’s caloric impact doesn’t always make a difference in our behavior. Studies assessing the impact of nutrition labeling in restaurants gave us a good picture of this complex issue: knowing an item’s calories either doesn’t alter behavior or can actually encourage higher calorie purchases (1, 2).

The good news is that controlling weight isn’t only about exercising willpower and skipping higher calorie items. Instead, we should focus on our diet’s composition.

Increasing food quality has a tremendous impact. This is not about emphasizing on macronutrient over another. Macronutrient categories are protein, carbohydrates, and fats. Instead, it’s about emphasizing micronutrients over macronutrients. Micronutrients, simply, are vitamins and minerals in foods. Foods that are micronutrient-dense tend to be the most satisfying. In a week to a few months of emphasizing micronutrients, one of the first things my patients notice is a significant reduction in macronutrient cravings.

Balancing protein, carbohydrates and fats

Many diets focus on the balance of macronutrients. Which has the greatest impact on weight loss? In a randomized control trial (RCT), when comparing different macronutrient combinations, there was very little difference among study groups, nor was there much success in helping obese patients reduce their weight (3, 4). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Focusing primarily on macronutrient levels and calorie counts did very little to improve results.

Should we avoid refined carbohydrates?

A small RCT showed refined carbohydrates actually may cause food addiction (5). MRI scans of trial subjects showed that certain sections of the brain involved in cravings and reward are affected by high-glycemic foods.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were not told which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

The authors note that this effect may occur regardless of the number of calories consumed. Commonly found high-glycemic foods include items like white flour, sugar, and white potatoes. We should all strive to limit or avoid refined carbohydrates.

Focusing on micronutrients 

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be micronutrient-deficient (6). This can have long-term impacts on your health that are not just related to weight. Micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements doesn’t solve the problem; generally, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised by increasing the variety of foods in your diet. Please, ask your doctor before starting or stopping supplements.

Cortisol levels and weight

While cortisol is important to an array of physiological processes, including regulating inflammation and blood pressure, too much cortisol can cause health problems. There is a complex dynamic between cortisol and weight. Cortisol raises glucose blood levels and is involved in promoting visceral or intra-abdominal fat. This type of fat coats internal organs. Decreasing your level of cortisol metabolite might also result in a lower propensity toward insulin resistance and decrease your risk of cardiovascular mortality.

In a preliminary, small, prospective (forward-looking) study involving women, results show that once obese patients lost weight, the levels of cortisol metabolite excretion decreased significantly (7). This is encouraging. Controlling or losing weight is more complex than calorie-counting. While calorie intake has a role, food’s nutrient density may play a significant role in reducing your cravings, ultimately helping you manage your weight.

References:

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) N Engl J Med 2009 Feb 26;360:859. (4) N Engl J Med 2009 Feb 26;360:923. (5) Am J Clin Nutr Online 2013;Jun 26. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

Dr. David 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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The microbiome affects our immune system responses

By David Dunaief, M.D.

Dr. David Dunaief

We have been hearing more frequent references to the microbiome recently in health discussions and healthcare marketing. So, what is it, and why is it important to our health?

We each have a microbiome, trillions of microbes that include bacteria, viruses and single-cell eukaryotes that influence our body’s functions. When “good” and “bad” microbes are in balance, we operate without problems. However, when the balance is tipped, often by environmental factors, such as diet, infectious diseases, and antibiotic use, it can make us more susceptible to inflammation, diseases and disorders.

We are going to focus on the gut microbiome, where much of our immune system response lives. Research into the specifics of our microbiome’s role in healthy functioning is still in its infancy. Current research into the microbiome’s effects include its role in obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

What affects our microbiome?

Lifestyle choices, like diet, can impact your microbiome positively or negatively. Microbiome diversity may vary significantly in different geographic locations throughout the world, because diet and other environmental factors play such a large role.

When we take medications, like antibiotics, we can wipe out our microbial diversity, at least in the short term. This is why antibiotics can cause gastrointestinal upset. Antibiotics don’t differentiate between good and bad bacteria.

One way to counteract an antibiotic’s negative effects is to take a probiotic during and after your course of antibiotics. I recommend taking Renew Life’s 30-50 billion units once a day, two hours after an antibiotic dose and continuing for 14 days after you have finished taking your prescription. If you need more protection, you can take one dose of probiotics two hours after each antibiotic dose.

Does the microbiome affect weight?

Many obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

For a long time, the weight loss “solution” had been to reduce caloric intake. However, extreme low-calorie diets were not having a long-term impact. It turns out that our gut microbiome may play important roles in obesity and weight loss, determining whether we gain or lose weight.

The results from a study involving human twins and mice are fascinating (2). In each pair of human twins, one was obese, and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. Interestingly, they only lost weight when on a good diet. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not yet clear which bacteria may be contributing to these effects.

Gut bacteria and autoimmune disease

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant joint soreness and joint breakdown. What if gut bacteria influences RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (3). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, can affect the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. Others are considering the effects of specific diets on the immune system and development of non-communicable diseases (5).

The promise of personalized medicine that helps individuals identify the perfect mix of microbes for them is still out in the future; however, many preliminary studies suggest important learnings that we can all use.

References:

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) Science. 2013;341:1241214. (3) PLoS One. 2012;7:e36095. (4) Nutrients. 2019 Dec;11(12):2862. (5) Nutrients. 2021 Feb 22;13(2):699.

Dr. David 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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Sleeping well can have positive long-term effects

By David Dunaief, M.D.

Dr. David Dunaief

It’s hard to avoid the flood of advertisements for products — from supplements to “brain games” — that promise to help us avoid cognitive decline as we age. Fear of slowing down cognitively as we age is a big driver of sales, I’m sure.

What do we really know about the brain, though?

We know that head injuries and certain drugs can have negative effects. Many neurological, infectious, and rheumatologic disorders can also have long-term effects. Examples include autoimmune and psychiatric mood disorders, diabetes and heart disease. In these cases, addressing the underlying medical issue is critical. 

Lifestyle choices also make a difference. Several studies suggest that we may be able to help our brains function more effectively by making simple lifestyle changes around our sleep and exercise habits. It’s also possible that taking omega-3s can help.

What is brain clutter?

Are 20-somethings more quick-witted than people over 60? It’s a common societal assumption.

German researchers put this to the test. They found that educated older people tend to have a larger mental database of words and phrases to draw upon when responding to a question (1). When this was factored into their simulation analysis, the difference in terms of age-related cognitive decline was negligible.

However, the more you know, the harder it can be to provide a simple answer to a question, leading to slower processing and response times.

Interestingly, a recent study that analyzed trends from three separate studies of brain health and aging found that older adults’ cognition has been increasing over time (2). The author notes that much of this can be attributed to environmental factors, such as education, healthcare and nutrition. Interestingly, younger adults’ cognition has not changed over the same study periods.

Let’s take a closer look at things we can control in our daily lives.

Regulating sleep

Researchers have identified two specific benefits we receive from sleep: clearing the mind and increased productivity.

For the former, a study done in mice shows that sleep may help the brain remove waste, such as beta-amyloid plaques (3). Excessive plaque buildup in the brain may be a sign of Alzheimer’s. When mice were sleeping, the interstitial space (the space between brain 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. A similar effect was seen when the mice were anesthetized.

An Australian study showed that sleep deprivation may have contributed to an almost one percent decline in gross domestic product (4). Why? When people don’t get enough sleep, they are not as productive. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness in the short term, we can’t do this continually.

One study found that sleep deprivation results were comparable to alcohol impairment (5). Subjects’ response time and accuracy with assigned tasks after 17-19 hours without sleep were the same or worse than their performance when they had a blood-alcohol concentration (BAC) of .05 percent. With more than 19 hours of sleeplessness, performance equaled .1 percent BAC.

Exercise’s impact

One study with rats suggests that a lack of exercise can cause unwanted new brain connections. Rats that were not allowed to exercise were found to have rewired neurons around their medulla, the part of the brain involved in breathing and other involuntary activities. This included more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (6). 

Among the rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. 

An analysis of 98 randomized controlled trials assessing exercise’s cognitive results in older adults, both with and without cognitive impairment, found that a minimum of 52 hours of physical exercise distributed over 25 weeks led to improvements in cognitive function. Physical exercise included aerobic, resistance (strength) training, mind–body exercises, or combinations of these. The authors suggest that, based on the data trends, benefits accumulate over time (7).

Omega-3 fatty acids

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

Specifically, the researchers looked at the levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes. The source of the omega-3 fatty acids was from either fish or supplementation.

While we have a lot to learn about maintaining brain function as we age, it’s comforting to know that we can positively influence it with lifestyle adjustments, including improving our sleep quality, exercising, and ensuring we consume enough omega-3 fatty acids.

References:

(1) Top Cogn Sci. 2014 Jan;6:5-42. (2) Dev Review. 2024 Mar 19 online. (3) Science. 2013 Oct. 18;342:373-377. (4) Sleep. 2006 Mar.;29:299-305. (5) Occup Environ Med. 2000 Oct;57(10):649-55. (6) J Comp Neurol. 2014 Feb. 15;522:499-513. (7) Neurol Clin Pract. 2018 Jun;8(3):257–265. (8) Neurology. 2014;82:435-442.

Dr. David 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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Get out and enjoy Spring!

By David Dunaief, M.D.

Dr. David Dunaief

Ah, the paradox of Spring. Trees and bushes are in full bloom, and flowers are popping up everywhere. For those with seasonal allergies — also known as allergic rhinitis or hay fever — it’s challenging to balance the desire to be outside with the discomfort it can bring.

According to the Centers for Disease Control and Prevention, 25.7 percent of U.S. adults and 18.9 percent of children were diagnosed with seasonal allergies in 2021 (1). Triggers include pollen from leafy trees, shrubs, grass, flowering plants, and weeds.

What prompts allergic reactions?

Sufferers experience a chain reaction when they inhale pollen. It interacts with immunoglobulin E (IgE), antibodies that are part of our immune system and causes mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes, and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response.

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). It can feel like a common cold, but without the virus. If you have symptoms that last more than 10 days and are recurrent, then it is more likely you have allergies than a virus.

If allergic rhinitis is not treated, it can lead to complications like ear infections, sinusitis, irritated throat, insomnia, chronic fatigue, headaches and even asthma (4).

What medications help? 

If you don’t want to seal yourself inside, to prevent allergy attacks, you might consider medications to reduce your symptoms.

Options include intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops.

The guidelines for treating seasonal allergic rhinitis with medications suggest that you use intranasal corticosteroids (steroids) when your quality of life suffers (5). Two commonly used inhaled steroids are triamcinolone (Nasacort) and fluticasone propionate (Flonase). They need to be used daily and can cause side effects, including headaches.

If itchiness and sneezing are your greatest challenges, second-generation oral antihistamines may be appropriate. These can be taken “as needed.” Examples include loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra). These have less sleepiness as a side effect than first-generation antihistamines, like Benadryl, but they don’t work for everyone.

Is butterbur an effective treatment?

Butterbur (Petasites hybridus) leaf extract has several small studies that indicate its efficacy in treating seasonal allergies. Butterbur is a shrub found in Europe, Asia and North America. 

In one randomized controlled trial (RCT) involving 131 patients, results showed that butterbur was as effective as cetirizine (Zyrtec) (6). In another RCT, results showed that high doses of butterbur — 1 tablet given three times a day for two weeks — was significantly more effective than placebo (7). Researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) in the trial.

A post-marketing follow-up study of 580 patients showed that, with butterbur Ze339, symptoms improved in 90 percent of patients with allergic rhinitis over a two-week period (8). Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the study population.

There are several important caveats about using butterbur. The leaf extract used in studies was free of pyrrolizidine alkaloids (PAs). PAs have been implicated in causing liver and lung damage and may cause cancer (9). Also, studies used well-measured doses, which may not be the case with over-the-counter extracts. Finally, there are interactions with some prescription medications.

If you are allergic to butterbur-related plants, such as ragweed, chrysanthemums, marigolds, and daisies, butterbur may cause an allergic reaction (9).

Can dietary changes treat seasonal allergies? 

There are no significant studies specifically on using diet; however, there is one literature review that suggests a plant-based diet may reduce symptoms of seasonal allergies in teens, as well as eczema and asthma (10). In my clinical practice, many patients with seasonal allergies have improved and even reversed the course of allergies over time with a vegetable-rich, plant-based diet. This might be due to its anti-inflammatory effects. Analogously, some physicians suggest that their patients have improved after removing dairy from their diets.

While allergies can make you miserable, there are many over-the-counter and prescription options to help. Diet may play a role by reducing inflammation. There does seem to be promise with butterbur extracts, there are caveats. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

References:

(1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) J Allergy Clin Immunol. 2003 Dec;112(6):1021-31.. (4) J Allergy Clin Immunol. 2010 Jan;125(1):16-29.. (5) Otolaryngol Head Neck Surg. 2015 Feb;2:197-206. (6) BMJ 2002;324:144. (7) Arch Otolaryngol Head Neck Surg. 2004 Dec;130(12):1381-6. (8) Adv Ther. Mar-Apr 2006;23(2):373-84. (9) ncchih.nih.gov. (10) Eur Respir J. 2001;17(3):436-443.

Dr. David 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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Exercises that involve balance, strength, movement, flexibility and endurance all play significant roles in fall prevention. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Taking a tumble can cause broken bones and torn ligaments. While these might not be life-altering in younger folks, they can have serious consequences for older patients, including a decrease in functional ability and a decline in physical and social activities, which can lead to a loss of independence (1)(2). One recent study found that older adults who had suffered a fall had poorer health and well-being two years later when compared to those who had not fallen (3).

What increases your fall risk?

Obviously, environmental factors, like slippery or uneven surfaces, can increase your risk of falling. Age and medication use are also contributing factors. Some medications, like those used to treat high blood pressure or those targeting anxiety, depression and insomnia, are of particular concern. Chronic diseases may also contribute.

If you have upper and lower body strength weakness, decreased vision, a hearing disorder or psychological issues, such as anxiety and depression, these conditions predispose you to falling (4).

How can you reduce your fall risk?

Most importantly, exercise. Exercises that involve balance, strength, movement, flexibility and endurance all play significant roles in fall prevention (5). The good news is that many of these can be done inside with no equipment or with items found around the home. We will look more closely at the research.

Nonslip shoes are a big help. Look for slippers and shoes with non-skid soles. During the winter, choose footwear that prevents sliding on ice, such as boots with cleats or slip-on ice cleats that fit over your shoes.

In the home, secure area rugs, remove tripping hazards, install grab-bars in your bathroom showers and tubs, and add motion-activated nightlights.

And, of course, always pay attention when you’re walking. Don’t text, read or video chat while you’re moving around. A recently published study of young, healthy adults found that texting while walking affected their gait stability and postural balance when they were exposed to a slip hazard (6).

How do medications increase risk?

Several medications heighten fall risk, including psychotropic drugs and high blood pressure medications.

A well-designed study showed that those taking moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase (7).

Because these medications can reduce cardiovascular risks, physicians must consider the risk-benefit ratio in older patients before prescribing or stopping a medication. We also should consider whether lifestyle modifications can reverse your need for medication or your dosage (8).

Using exercise to reduce fall risk

A meta-analysis showed that regular exercise significantly reduced the risk of a fall (9). It led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in falls that required medical attention. Even more impressive was a 61 percent reduction in fracture risk. The author summarized that exercise not only helps to prevent falls but also fall injuries.

Unfortunately, those who have fallen before often develop a fear that leads them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased fall risk (10).

Any consistent exercise program that focuses on flexibility and muscle tone and includes core strengthening can help improve your balance. Among those that have been studied, tai chi, yoga and aquatic exercise have all been shown to reduce falls and injuries from falls.

A randomized controlled trial showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (11). The goal of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the overall number of falls and a 44 percent decline in the number of exercising patients who fell during the six-month trial, with no change in the control group.

Tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (12).

Another pilot study used modified chair yoga classes with a small, over-65 assisted-living population where participants had experienced a recent fall and had a resulting fear of falling (13). While the intention was to assess exercise safety, researchers found that participants had less reliance on assistive devices and three of the 16 participants were able to eliminate their use of mobility assistance devices.

Our best defense against fall risk is prevention with exercise and managing our environments to reduce fall opportunities. In addition, if you are 65 and older, or if you have arthritis and are over 45, it may mean reviewing your medication list with your doctor. Before you consider changing your blood pressure medications, review your risk-to-benefit ratio with your physician.

References:

(1) MMWR. 2014; 63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) Aging Ment Health. 2021 Apr;25(4):742-748. (4) JAMA. 1995;273(17):1348. (5) Cochrane Database Syst Rev. 2012;9:CD007146. (6) Heliyon. 2023 Aug; 9(8): e18366. (7) JAMA Intern Med. 2014 Apr;174(4):588-595. (8) JAMA Intern Med. 2014;174(4):577-587. (9) BMJ. 2013;347:f6234. (10) Age Ageing. 1997 May;26(3):189-193. (11) Menopause. 2013;20(10):1012-1019. (12) Mater Sociomed. 2018 Mar; 30(1): 38–42. (13) Int J Yoga. 2012 Jul-Dec; 5(2): 146–150.

Dr. David 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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 Obesity can influence your body’s ability to use vitamin D

By David Dunaief, M.D.

Dr. David Dunaief

Happy Spring! It’s been a rougher winter than in recent years, and the additional hours of sunshine each day seem even more welcome than usual.

The extra sunshine is also good news for your vitamin D3 levels. Realistically, though, it’s still challenging to get enough sun exposure to meet your vitamin D requirements without putting yourself at risk for developing skin cancer. Even without this concern, sun exposure doesn’t address all our vitamin D needs. In a study of Hawaiians, a subset of the study population with more than 20 hours of sun exposure without sunscreen per week still had some participants with low vitamin D3 values (1).

This is why many of us rely on food-sourced vitamin D from fortified packaged foods, where vitamin D3 has been added. 

Why do we care about vitamin D? Studies have shown that it may be effective in preventing and treating a wide swath of chronic diseases. If you have low levels of vitamin D, replacing it is important. There’s still a lot we don’t know, though.

For example, there is no consensus on the ideal blood level for vitamin D. For adults, the Food and Nutrition Board (FNB) at the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine (IOM)) recommends between 20 and 50 ng/ml (2). The Endocrine Society updated their testing and supplementation recommendations in 2024 to stratify them by age and pregnancy status, among other risk factors (3). Generally, however, they do not recommend testing vitamin D3 levels for healthy adults and defer to the IOM for supplementation recommendations.

How does body fat affect Vitamin D absorption?

Data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, suggests that participants with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (4). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs did not experience these benefits.

According to the National Institutes of Health (NIH), those with obesity issues might need greater intakes of vitamin D to achieve vitamin D levels similar to those of people with lower weights, because subcutaneous fat sequesters vitamin D, making it unavailable for their systems to use (2).

Does vitamin D improve cardiovascular health?

Several observational studies have shown benefits from vitamin D supplementation with cardiovascular disease. The Framingham Offspring Study showed that patients with deficient levels were at increased risk of cardiovascular disease (5).

In contrast, though, a small randomized controlled trial (RCT) questioned the cardioprotective effects of vitamin D (6). 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. 

An NIH review of both observational and randomized clinical trials concluded that, even for those with low vitamin D levels, supplementation does not reduce cardiovascular disease risk (2). 

How does vitamin D affect your weight?

There is moderately good news on the weight front. The Study of Osteoporotic Fractures found that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels were more than 30 ng/ml (7).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this 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, sufficient vitamin D did not result in weight loss.

Does vitamin D supplementation reduce fracture risk?

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D3 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (8). The combination does not seem to reduce fractures, but it does increase the risk of kidney stones.

Should you supplement your vitamin D3?

While vitamin D may not be a cure-all, it might play a role with many disorders. It is important to supplement to optimal levels, especially since many of us living in the Northeast have insufficient to deficient levels. This is especially important for those with specific health issues that are affected by low vitamin D levels. However, it is important not to raise your blood levels too high (9). I advise my patients to target a range between 32 and 50 ng/ml, depending on their health circumstances.

References:

(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) nih.gov. (3) JCEM, August 2024 (online June 2024). (4) JAMA Netw Open. 2023 Published online Jan 2023. (5) Circulation. 2008 Jan 29;117(4):503-511. (6) PLoS One. 2012;7(5):e36617. (7) J Clin Endocrinol Metabol. May 17, 2012 online. (8) JAMA. 2018;319(15):1592-1599. (9) Am J Lifestyle Med. 2021 Jul-Aug; 15(4): 397–401.

Dr. David 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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It doesn’t take much exercise to improve health outcomes. METRO photo

By David Dunaief, M.D.

As I wrote last week, exercise is not the sole solution for weight loss. However, it can improve our outcomes with diseases and other health issues. It may also play a significant role in altering how our genes express themselves. The list of conditions it can improve includes diabetes, kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Even knowing all the positive impacts, motivating yourself to exercise can be difficult. There are some simple ways to motivate yourself during exercise. One study showed that those who repeated positive mantras to themselves during exercise were able to continue for longer periods (2).

Why is this so important? Because we are too sedentary. According to data from the 2017-2020 Behavioral Risk Factor Surveillance System, New York had among the highest levels of physical inactivity in the U.S., at 25.9 percent of the population (3).

Can exercise alter your genes?

While it may not change our genes, exercise may change how our genes express themselves.

One study’s results showed that, when participants exercised for six months, many thousands of genes in fat cells were affected (4). During the study, previously sedentary men took a one-hour spin class twice a week. According to the researchers, this exercise affected genes involved in storing fat and in risk for subsequent diabetes and obesity development. The participants also improved other important health metrics, including cholesterol, blood-pressure, fat percent and, over time, waist circumferences.

Epigenetics is when lifestyle changes ultimately lead to changes in how genes express themselves, turning genes on and off. While this effect has been shown with dietary changes, this is one of the first studies to show that exercise also impacts our genes. It took only six months to see these numerous gene changes with a modest amount of cardiovascular exercise.

Need more inspiration? Another study showed considerable gene changes in muscle cells after one stationary bike workout (5). Yet another introduced six weeks of endurance exercise to healthy, but sedentary, young men and identified an abundance of genetic changes to skeletal muscle, which broadly affects physical and cognitive health (6).

How does exercise affect cardiovascular disease?

One meta-analysis examined 57 studies that involved drugs and exercise. It showed similar mortality benefits with statins and exercise for patients who already have coronary heart disease (7). Both statins and exercise reduced the risk of mortality by similar amounts. The same study also showed that, for those with pre-diabetes, it didn’t matter whether they took metformin or exercised — each had the same effect.

While these results are exciting, don’t change your medication without consulting your physician.

Exercise and kidney stone prevention

Passing a kidney stone can be excruciating. Most treatments involve taking pain medication and fluids and just waiting for the stone to pass. Honestly, the best way to treat kidney stones is to prevent them.

The Women’s Health Initiative Observational Study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones. It found exercise reduced kidney stone risk by as much as 31 percent (8). Even better, exercise intensity did not alter its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results; however, lesser amounts of exercise also saw substantial reductions.

Exercise can have strong influences on the way you feel; however, it may also influence your genes’ expression and, ultimately, affect the development and prevention of disease. In certain circumstances, it may be as powerful as medications and, in combination, can pack a powerful punch.

References:

(1) JAMA. 2009;301(19):2024. (2) Med Sci Sports Exerc. 2013 Oct 10. (3) cdc.gov. (4) PLoS Genet. 2013 Jun;9(6):e1003572. (5) Cell Metab. 2012 Mar 7;15(3):405-11. (6) Mol Metab. 2021 Nov;53:101290. (7) BMJ. 2013; 347. (8) JASN. 2013;24(3):p 487-497.

Dr. David 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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Exercise is an inadequate weight-loss tool

By David Dunaief, M.D.

Dr. David Dunaief

We hear continuously about the importance of exercise. Why is it so important, though? Exercise has benefits for preventing and improving a wide range of medical conditions, from cardiovascular disease, chronic kidney disease, and diabetes to depression, insomnia, fatigue, balance, cognitive decline, and osteoporosis. Will it help you lose weight, though? While gym equipment ads emphasize this, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). It may only reduce fat mass and weight modestly for most people. It might, however, be helpful with weight maintenance.

Ultimately, it may be more important to examine what you are eating than to succumb to the rationalization that you can eat without care and work out to compensate for that extra cookie.

Does exercise help with weight loss?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will promote weight loss. However, study results 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.

However, more than two-thirds of the women 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. A fair amount of 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, which is characterized as a moderately intense pace.

On the positive side, the women were in better aerobic shape by the study’s end. Also, women who had lost weight at four-weeks were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that exercise alone led to a disappointing amount of weight loss (4). In six months, patients lost a mean of 3.5 pounds, and at 12 months, they lost about 3.75 pounds.

A recent meta-analysis of aerobic exercise studies found that, in order to break through to meaningful reductions in waist circumference and body fat, participants had to exercise more than 150 minutes per week, up to 300 minutes weekly, at moderate to vigorous aerobic intensity (5).

However, exercise may help with weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (6). In another study, when exercise was added to dietary changes, women were able to maintain 30 percent more weight loss than with diet alone after a year (7).

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects about 14 percent of U.S. adults, as one example of exercise’s impact on disease (8).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (9). When walkers were compared to non-walkers, walkers experienced a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death.

The more frequently patients walked during 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 a week saw a 44 percent reduction in death and a 59 percent reduction in kidney replacement. This is significant. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

There are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

References:

(1) Diabetes Spectr. 2017 Aug;30(3):157–160. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) JAMA Netw Open. 2024;7(12):e2452185. (6) Obesity (Silver Spring). 2010;18(1):167. (7) Int J Obes Relat Metab Disord. 1997;21(10):941. (8) cdc.gov. (9) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

Dr. David 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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