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Focus on reducing pain and improving mobility

By David Dunaief, M.D.

Dr. David Dunaief

Osteoarthritis has been diagnosed in over 54 million Americans, with 43.5 percent of them reporting symptoms that limit their activities and significantly impact their quality of life (1). Historically, the disorder was thought to be solely a wear-and-tear degeneration of the joint(s). However, Osteoarthritis (OA) also involves inflammation with the release of cytokines and prostaglandins — inflammatory factors — which cause joint destruction and pain (2).

The joints most commonly affected include the ankle, knee, hip, spine and hand. OA may affect joints asymmetrically, meaning that it affects a joint on only one side of the body.

Mainstays of treatment include analgesics and COX-2 inhibitors (Celebrex). Common analgesics used are acetaminophen and NSAIDs, such as ibuprofen (Advil), naproxen sodium (Aleve). A benefit of NSAIDs is that they have anti-inflammatory effects. Meanwhile, COX-2 inhibitors may also improve joint mobility.

There are adverse effects with NSAIDs, including increased gastrointestinal (or GI) bleed and, with long-term use, an increase in cardiovascular events, such as heart attacks, with the elderly being most susceptible.

Neither medication type, however, structurally modifies the joints. In other words, they may not slow OA’s progression nor rebuild cartilage or the joint space as a whole. Are there therapies that can accomplish these feats and, if so, what are they? We will look at hyaluronic acid, glucosamine and chondroitin, and lifestyle modifications such as exercise and weight loss.

Chondroitin sulfate beneficial for hand OA

The results with the use of glucosamine and chondroitin have been mixed, depending on the joints affected. In the FACTS trial, a randomized controlled trial, chondroitin sulfate by itself showed significant improvement in pain and function with OA of the hand (3). The dose of chondroitin used in the study was 800 mg once a day. The patients, all of whom were symptomatic at the trial’s start, also saw the duration of their morning stiffness shorten.

There was also a modest reduction in structural damage of hand joints after three months, compared to placebo. The benefit was seen with prescription chondroitin sulfate, so over-the-counter supplements may not work the same way. Patients were allowed to use acetaminophen, and there was no change in dose or frequency throughout the trial.

Crystalline glucosamine sulfate

In knee OA, crystalline glucosamine sulfate showed reduction in pain and improvement in functioning in a randomized controlled trial (4). When assessed by radiologic findings, it also slowed the progression of structural damage to the knee joint. In other words, the therapy may have disease-modifying effects over the long term. The glucosamine formulation may work by inhibiting inflammatory factors such as NF-kB. The trial used 1500 mg of prescription crystalline glucosamine sulfate over a three-year period. Again, it’s not clear whether an over-the-counter supplement works the same way.

Glucosamine and/or chondroitin for knee OA

In a meta-analysis (group of 10 studies), glucosamine, chondroitin or the combination did not show beneficial effects — reduced pain or mobility changes — in patients when compared to placebo (5). It was not clear whether supplemental or prescription-level therapies were used in each trial — or whether that makes a difference. This study was published prior to the crystalline glucosamine sulfate trial of the knee, discussed above, which did show statistical significance.

There is not much downside to using glucosamine and/or chondroitin for OA patients. However, use caution if taking an anticoagulant (blood thinner) like Coumadin, since glucosamine has anticoagulant effects. Also, those with shellfish allergies should not use glucosamine. If there is no effect within three months, it is unlikely that glucosamine and/or chondroitin are beneficial.

Hyaluronic acid

In a meta-analysis (a group of 89 trials), the risks outweighed the benefit of hyaluronic acid, a drug injected into the joint for the treatment of OA (6). Viscosupplementation involves a combination of hyaluronic acid types that act as a shock absorber and lubricant for the joints. Some of the studies did show a clinical benefit. However, the authors believe that adverse local events, which occurred in 30 to 50 percent of patients, and serious adverse events, with 14 trials showing a 41 percent increased risk, outweigh the benefits. Since there are mixed results with the trials, it is best to discuss this option with your physician.

Impact of weight loss and exercise

Obesity treatment with a weight-loss program actually has potential disease-modifying affects with OA (7). It may prevent cartilage loss in the medial aspect of the knee. The good news is that, even with as little as a seven percent weight loss in the obese patient, these results were still observed. The study’s average weight loss was nine to 10 pounds, and results were seen on a dose-response curve — the greater the weight loss, the thicker the knee cartilage.

Writing in The New England Journal of Medicine, Dr. David Felson observed there is an inverse relationship between the amount of muscle-strengthening exercise, especially of the quadriceps, and the amount of pain experienced in the knee joint. It is very important to do nonimpact exercises such as leg raises, squats, swimming, bicycling and on elliptical machines.

Fortunately, there are a number of options to prevent, treat and potentially modify the effects of OA. With weight loss in the obese patient, quality of life can dramatically increased. Glucosamine and/or chondroitin may be of benefit, depending on the joints affected. The benefits are potential improvements in pain, mobility and structural-modifying effects, which are worth the risk for many patients. When taking glucosamine and/or chondroitin in supplement form, ConsumerLab.com may be a good source for finding a supplement where you get the dose claimed on the box. I would also use formulations in the trials that showed results, even in supplement form.

References:

(1) MMWR Morb Mortal Wkly Rep. 2017 Mar 10;66(9):246-253. (2) Rheumatology. 2011;50(12):2157-2165. (3) Arthritis Rheum. 2011 Nov;63(11):3383-91. (4) Ther Adv Musculoskel Dis. 2012;4(3):167-180. (5) BMJ. 2010;341:c4675. (6) Ann Intern Med. 2012;157(3):180-191. (7) Ann Rheum Dis. 2012;71(1):26-32.

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.

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Watching four or more hours of television has shown to cause an increased risk of cardiovascular disease mortality of 80 percent. METRO photo
Expanded viewing habits have effects on your physical and mental health

By David Dunaief, M.D.

Dr. David Dunaief

Comcast, one of America’s largest cable and internet providers, reported in May that Americans were watching an additional 8-plus hours of programming a week, whether on a television, computer or a portable device since the pandemic’s beginning (1). For our purposes, we’ll call this TV, because most is consumed while sitting, although the average watching modality has shifted considerably.

What impact does all this watching have on our lives? It may be hazardous to your health. I know this seems obvious, but bear with me. The extent of the effect is surprising. According to 2013 Netflix research, binge-watching, or watching more two or more episodes of a single program in a row, is perceived as providing a refuge from our busy lives.

This also has an addictive effect, prompting dopamine surges as we watch. Interestingly, it also can lead to post-binge depression when a show ends and to isolation and lower social interaction while viewing (2). Of course, while socially isolating, binge watching can help kill hours, but the negative effects are still relevant.

TV’s detrimental effect extends beyond the psychological, potentially increasing the risk of heart attacks, diabetes, depression, obesity and even decreasing or stunting longevity. My mother was right when she discouraged us from watching television, but I don’t think even she knew the extent of its impact.

Cardiovascular events including heart attacks

There was a very interesting observational study published in the New England Journal of Medicine that showed watching sporting events increases the risk of heart attacks and other cardiovascular events, such as arrhythmia (irregular heartbeat) and unstable angina (severe chest pain ultimately due to lack of oxygen). The researchers followed Germans who watched the FIFA (soccer) World Cup playoffs in 1996.

How much did watching increase the risk of cardiovascular events? This depended on what round of the playoffs and how close a game it was. The later the round and the closer the game, the greater the risk of cardiovascular events. Knockout games, which were single elimination, seemed to have the greatest impact on cardiovascular risk.

When Germany was knocked out in the semi-finals, the finals between France and Italy did not have any cardiovascular effect.

Overall, men experienced a greater than three-fold increase in risk, while women experienced an increased risk that was slightly below two-fold. According to the authors, it was not the outcome of the game that mattered most, but the intensity. The study population involved 4,279 German residents in and around the Munich area (3).

Another study found that, compared to fewer than two hours a day, those who watched four or more hours experienced an increased risk of cardiovascular disease mortality of 80 percent. I know this sounds like a lot of TV, but the average daily American viewing time is significantly over this. This study, called the Australian Diabetes, Obesity, and Lifestyle study (AusDiab) was observational looking at 8800 adults over a six-year period (4).

Impact on Life Expectancy

The adage that life tends to pass you by when you watch TV has a literal component. An observational study found that TV may reduce the life expectancy of viewers. In the study, those who watched at least six hours per day during their lifetime had a decrease in longevity of 4.8 years. However, this is not the whole story. What is even more telling is that after the age of 25, for every hour of TV, one might expect to potentially lose 21.8 minutes of life expectancy (5). According to the authors, these results rival those for obesity and sedentary lifestyles.

Diabetes and Obesity Risk

In the Nurses’ Health Study, for every two hours of television viewing on a daily basis there were increased risks of type 2 diabetes and obesity of 23 percent and 14 percent, respectively (6). The results show that sitting at work for two hours at time increased the risk of diabetes and obesity by only five percent and seven percent respectively, much less of an effect than TV-watching. The authors surmise that we can reduce the incidence of diabetes and obesity by 43 percent and 30 percent by cutting our TV time by 10 hours a week.

Modestly reducing the amount of television is a simple lifestyle modification that can have a tremendous impact on longevity, quality of life and prevention of the top chronic disease. So, step away from your television, tablet or computer and take a walk outside, do some calisthenics, or even take up a new hobby that doesn’t involve sitting on the couch. Your body and your psyche will thank you.

References:

(1) corporate.comcast.com (2) nbcnews.com/better/health/what-happens-your-brain-when-you-binge-watch-tv-series-ncna816991. (3) N Engl J Med 2008; 358:475-483. (4) Circulation. 2010 Jan 26;121(3):384-91. (5) Br J Sports Med doi:10.1136/bjsm.2011.085662. (6) JAMA. 2003 Apr 9;289(14):1785-91.

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.

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White fleshy fruits like apples, pears and bananas have shown to decrease ischemic stroke risk. Stock photo
Medications and lifestyle play important roles

By David Dunaief

Dr. David Dunaief

Stroke remains one of the top five causes of mortality and morbidity in the United States (1). While some risk factors are out of our control, like family history and age, many of our risks can be altered by making lifestyle changes and managing contributing diseases, like hypertension and diabetes.

We have a wealth of studies that inform us on the roles of medications and lifestyle in managing risk. Of particular importance are medication guidelines that balance the risks and benefits of different stroke prevention regimens.

Medications can be protective

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. Some studies have shown reduced mortality from stroke in patients who were on statins at the time of the event (2). Patients who were on a statin to treat high cholesterol had an almost six-fold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (3).

It is important to recognize that high blood pressure and high cholesterol are two of the most significant risk factors for stroke. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Use caution with medication combinations

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (4, 5).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Managing aspirin dosing

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day, an adult dose, it would result in 900,000 major bleeding events per year (6). Do not take an aspirin regimen — even a low-dose aspirin regimen — for stroke prevention without consulting your physician.

Protection from fruits and vegetables

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (7). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (8). The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (9). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose-related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — typically low-dose aspirin — since the risk of a second stroke is high.

References:

(1) cdc.gov. (2) AAN conference: April 2012. (3) Am J Cardiol 2012; 109(9):1308-1314. (4) ISC 2012; Abstract LB 9-4504; (5) www.clinicaltrials.gov NCT00059306. (6) JAMA 2007;297:2018-2024. (7) Stroke. 2011; 42: 3190-3195. (8) J. Nutr. 2011;141(8):1552-1558. (9) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

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.

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Studies have shown that combined strength and endurance training may lower RHR in women. METRO photo
Certain types of exercise may lower RHR

By David Dunaief, M.D.

Dr. David Dunaief

How many of us regularly check our resting heart rate, or pulse, and what can we learn from it?

Resting heart rate is pretty important. In fact, it may play a role in longevity, heart disease — including heart failure, arrhythmias, heart attacks and sudden cardiac death — and even chronic kidney disease.

A “normal” resting heart rate is between 60 to 100 beats per minute (bpm). If your resting heart rate (RHR) is above 100 bpm, this is referred to as tachycardia, or a racing heartbeat, and it has potentially serious consequences. However, even normal RHRs can be stratified to identify risks for diseases. What I mean is that, even in the normal range, as your RHR increases, so do your potential risks. Actually, resting heart rate below approximately 70 bpm may be ideal.

The good news is that RHR is modifiable. Methods that may reduce your rate include medications, such as beta blockers, and lifestyle modifications, including meditation, dietary changes and exercise.

Impact on life span

Reducing RHR may be an important component in living a longer, healthier lifestyle. In the Copenhagen Male Study, a prospective study that followed 2,798 participants for 16 years, results showed that those with higher resting heart rates had a greater risk of death (1). There was a linear relationship between the risk of death and increasing RHR. Those who had a resting heart rate above 90 bpm were at a threefold greater risk of death, compared to those who had a RHR at or below 50 bpm. RHR was inversely related to the amount of physical activity.

Thus, the authors concluded that a “healthy” person with higher RHR may still have a shorter life span, with all other factors being equal, such as physical activity and blood pressure.

Predictor of Hypertension?

An analysis of 4,000 young adult participants in the 30-year CARDIA cohort study found that a 10 bpm higher RHR had a significant impact on future hypertension, or high blood pressure, experienced in middle age (2). This association was found with a 10 bpm increase in RHR among black and white men and white women. Interestingly, black women did not show the same association. The study authors hypothesize that this may suggest racial differences in sympathetic nervous activity impacts on hypertension among women. Of course, additional research will be necessary to delve deeper into this.

Heart disease mortality

In the Nord-Trondelag Health Study, a prospective observational study, those who had a higher RHR at the end of the study than they did at the beginning of the study 10 years prior were more likely to die from heart disease (3). In other words, as the RHR increased from less than 70 bpm to over 85 bpm, there was a 90 percent greater risk of heart disease, compared to those who maintained a RHR of less than 70 throughout the two measurements. This study involved 30,000 participants who were healthy volunteers at least 20 years old.

Heart attacks

In the Women’s Health Initiative, results showed a 26 percent decrease in the risk of cardiovascular events in those postmenopausal women who had a RHR below 62 bpm, compared to those who had a RHR above 76 bpm (4). Interestingly, these results were even more substantial in the subgroup of women who were newly postmenopausal, ranging in age from 50 to 64.

Effect on kidney function

I have written many times about chronic kidney disease. An interesting follow-up is resting heart rate and its impact on kidney function. In the Atherosclerosis Risk in Communities Study, results showed that the most severe form of chronic kidney disease, end-stage renal disease, was 98 percent more likely to occur in those with the highest RHR, compared to those with the lowest (5). There were approximately 13,000 participants in the study, with a 16-year follow-up.

The authors hypothesized that this negative effect on the kidney may be due to a loss of homeostasis in the autonomic (involuntary) nervous system, resulting in blood vessel dysfunction, such as increased inflammation and vasoconstriction (narrowing).

Lowering RHR

Studies have shown that combined strength and endurance training may lower RHR in women. METRO photo

A meta-analysis of controlled studies analyzed the effects of different types of exercise on RHR (6). Studies’ interventions included a range of exercises, such as high intensity interval training, including ball and team sports; endurance or strength training; yoga; qigong; and tai chi. Some studies’ participants were limited to one gender.

No surprise, analysis found that all interventions lowered RHR compared to control groups that did not exercise. The greatest results in lowering RHR were in endurance training, yoga, strength training (females only), and combined endurance and strength training (females only).

Can RHR be too low?

Is there a resting heart rate that is too low? Well, it depends on the context. If you are a marathoner or an athlete, then a RHR in the 40s may not be abnormal. For a healthy, physically active individual, it is not uncommon to have a resting heart rate in the 50s. However, if you are on medications that reduce your RHR and/or have a chronic disease, such as heart failure, it is probably not advisable to go much below 60 bpm.

Always ask your doctor about the appropriate resting heart rate for your particular situation.

Thus, resting heart rate is an easy and inexpensive biomarker to potentially determine risk stratification for disease and to increase longevity, even for those in the normal range. By monitoring and modifying RHR, we can use it as a tool for primary disease prevention.

References:

(1) Heart Journal 2013 Jun;99(12):882-887. (2) Hypertension. 2020 Sep;76(3):692-698. Epub 2020 Aug 12. (3) JAMA 2011; 306:2579-2587. (4) BMJ. 2009 Feb 3;338:b219. (5) J Am Soc Nephrol. 2010 Sept;21(9):1560-1570. (6) J Clin Med. 2018 Dec; 7(12): 503.

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.

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Exercise plays a crucial role in lowering blood pressure. Stock photo
Nighttime pressure readings may better predict cardiovascular events

By David Dunaief, M.D.

Dr. David Dunaief

Roughly 45 percent of adults in the U.S. have hypertension, or high blood pressure. That’s almost one in two adults, or 108 million people, of which 82 million do not have their hypertension con-trolled. If that isn’t scary enough, the Centers for Disease Control and Prevention (CDC) reports that almost a half-million people died in the U.S. in 2017 from complications of hypertension in 2017 (1).

Speaking of scary, the probability of complications, such as cardiovascular events and mortality, may have their highest incidence during nighttime sleeping hours.

Unfortunately, as adults, it does not matter what age or what sex you are; we are all at increased risk of complications from high blood pressure. Fortunately, hypertension is highly modifiable in terms of reducing the risk of cardiovascular disease and mortality (2). At least some of the risk factors are probably familiar to you. These include being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits. These include lifestyle modifications with diet, exercise and potentially supplements.

Risk factors matter, but not equally

In an observational study involving 2,763 participants, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (4). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²), which put participants at 1.87 times increased risk. This surprisingly, albeit slightly, trumped cigarette smoking at 1.83 times increased risk.

The moral is that a freewheeling lifestyle can have a detrimental impact on blood pressure and cause at least stage 1 hypertension.

Hypertension complications are felt across gender, age and race

While the data show that more men than women have hypertension, 47 percent vs. 43 percent, and the prevalence of high blood pressure varies by race, the consequences of hypertension are felt across the spectrum of age, gender and race (1).

One of the most feared complications of hypertension is cardiovascular disease. In a study, isolated systolic (top number) hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (5). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, it was very large and had a 31-year duration.

Nighttime concerns

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (6).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration. Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (7). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

Previously, a study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Eat your berries

Diet plays a role in controlling high blood pressure. In a study, blueberry powder (22 grams) in a daily equivalent to one cup of fresh blueberries reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (9).

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase a substance called nitric oxide, which helps blood vessels relax, reducing blood pressure.

In conclusion, nighttime can be scary for high blood pressure and its cardiovascular complications, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References:

(1) CDC.gov. (2) Diabetes Care 2011;34 Suppl 2:S308-312. (3) uptodate.com. (4) BMC Fam Pract 2015;16(26). (5) J Am Coll Cardiol 2015;65(4):327-335. (6) J Am Coll Cardiol 2015;65(4):327-335. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377. (10) JAMA Pediatr online April 27, 2015.

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.

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Even over-the-counter medications carry risks and can lead to health problems. Stock photo
Use caution and follow the label instructions with NSAIDs and acetaminophen

By David Dunaief, M.D.

Dr. David Dunaief

Most of us keep a few stock items in our medicine cabinets as our “go-to’s” for pain relief, fever or inflammation.

In addition to aspirin, among these are usually other NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophen (Tylenol). Familiar NSAIDs include ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). Over 70 million prescriptions for NSAIDs are written each year in the U.S., and Americans consume more than 30 billion doses, once over-the-counter (OTC) use is factored in (1).

According to a poll of these regular users of OTC NSAIDs, a substantial number — 60 percent — were unaware of their dangerous side effects (2). Acetaminophen is used frequently, as well. One quarter of Americans take it on a weekly basis.

Unfortunately, many think of these drugs as relatively benign. In fact, I find that until I specifically ask about their use, most patients don’t include them in a list of their medications.

The risks

Unfortunately, NSAIDs, according to the Centers for Disease Control and Prevention, are responsible for 7,600 deaths annually and 10 times that number in hospitalizations (3). These are not medications that should be taken lightly. NSAIDs increase the risk of several maladies, including heart attacks, gastrointestinal bleeds, exacerbation of diverticular disease, chronic arrhythmias (abnormal heartbeats) and erectile dysfunction. In some instances, the cardiovascular effects can be fatal.

These risks prompted the FDA to strengthen the warning labels on non-aspirin NSAID labels, advising that those taking NSAIDs should immediately seek medical attention if they experience chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech (4).

Adverse side effects of NSAIDs

In a case control (epidemiologic, retrospective) study using the UK Primary Care Database, chronic users of NSAIDs have a significantly increased risk of a serious arrhythmia (abnormal heartbeat) called atrial fibrillation (5). Patients were between 40 and 89 years of age.

Interestingly, chronic users were defined as patients who took NSAIDs for more than 30 days. Those patients who used NSAIDs more than 30 days had a 57 percent increased risk of atrial fibrillation. A Danish study reinforces these results after the first month of use (6). This is not very long to have such a substantial risk. For patients who used NSAIDs longer than one year, the risk increased to 80 percent. Caution should be used when prescribing NSAIDs or when taking them OTC. Atrial fibrillation is not an easy disease to treat.

NSAIDs also increase the risk of mortality in chronic users. Older patients who have heart disease or hypertension (high blood pressure) and are chronic NSAIDs users are at increased risk of death, according to an observational study (7). Compared to those who never or infrequently used them over about 2.5 years, chronic users had a greater than twofold increase in death due to cardiovascular causes. High blood pressure was not a factor, since the chronic users actually had lower blood pressure. Yet I have seen with my patients that NSAIDs can increase blood pressure.

Acetaminophen as an alternative?

Acetaminophen does not cause gastrointestinal bleeds, arrhythmias and deaths due to cardiovascular events that NSAIDs can. However, the Food & Drug Administration announced in 2011 that acetaminophen should not exceed 325 mg every four to six hours when used as a prescription combination pain reliever (4). The goal is to reduce and avoid severe injury to the liver, which can potentially cause liver failure.

There is an intriguing paradox with acetaminophen: Hospitals typically dispense regular-strength 325-mg doses of the drug, whereas OTC doses frequently are found in extra-strength 500-mg tablets, and often the suggested dose is two tablets, or 1 gram. Patients should not take more than 4 grams a day to lower their risk of liver damage. The 4 gram amount sounds like a significant quantity, but it translates into two pills of extra-strength Tylenol every six hours.

I have patients who have taken three pills at one time thinking that, since it is OTC, exceeding the dose is okay. Unfortunately, this is not true and can be dangerous.

The FDA’s recommendations for limiting the dose result from a conglomeration of data. For instance, one study that showed acute liver failure was due primarily to unintentional overdoses of acetaminophen (8). Accidental overdosing is more likely to occur when taking acetaminophen at the same time as a combination sinus, cough or cold remedy that also contains acetaminophen. Over-the-counter cold medications can contain acetaminophen.

In order to be aware of potentially adverse events, you have to be your own best advocate and read labels. Remember to tell your physician if you are taking OTC medications. If you are a chronic user of NSAIDs because of underlying inflammation, you may find an anti-inflammatory diet, which is usually plant-based, is an effective alternative.

References:

(1) Medscape.com, 2020 May 30 (emedicine.medscape.com/article/816117-overview). (2) J Rheumatol. 2005;32;2218-2224. (3) Annals of Internal Medicine, 1997;127:429-438. (4) fda.gov (5) Arch Intern Med. 2010;170(16):1450-1455. (6) BMJ 2011;343:d3450. (7) Am J Med. 2011 Jul;124(7):614-620. (8) Am J Gastroenterol. 2007;102:2459-2463.

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.

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Walking helps strengthen your joints, bones and muscles. METRO photo
Walking’s benefits extend beyond physical fitness

By David Dunaief, M.D.

Dr. David Dunaief

There is great emphasis on exercise in medicine and in society. We have heard it is good for us ever since we were children in gym class striving for the presidential fitness award.

The average reaction, unfortunately, is an aversion to exercise. As kids, many of us tried to get out of gym class, and as adults, we “want” to exercise, but we “don’t have time.” The result of this is a nation of couch potatoes. I once heard that the couch is the worst deep-fried food. It perpetuates inactivity, especially when watching TV. Even sleeping burns more calories.

I think part of the problem, generally, is that we don’t know what type of exercise is best and how long and frequently to do it. These days, for many who depend on gyms, dance studios and other exercise-related facilities for exercise are struggling to find meaningful substitutes.

Well, guess what? There is an easy way to get tremendous benefit with very little time involved. You don’t need expensive equipment, and you don’t have to join a gym. You can sharpen your wits with your feet.

Jane Brody has written in The New York Times’ Science Times about Esther Tuttle. Esther was 99 years old, sharp as a tack and was independently mobile, with no aids needed. She continued to stay active by walking in the morning for 30 minutes and then walking again in the afternoon. The skeptic might say that this is a nice story, but its value is anecdotal at best.

Well, evidence-based medicine backs up her claim that walking is a rudimentary and simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away.

Walking has a powerful effect on preserving brain function and even growing certain areas of the brain (1). Walking between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years.

Those participants who had an increase in brain tissue volume had a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants who had a mean age of 78 and were dementia free at the start of the trial. Imagine if you started earlier?

In yet another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2).

Even better news is that, if you’re pressed for time or if you’re building up your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile? You’ll be surprised at how much better you will feel — and how much sharper your thinking is.

This is a terrific strategy to get you off the couch or away from your computer, another hazard for many of us working or schooling from home. Set an alarm for specific points throughout the day and use that as a prompt to get up and walk, even if only for 15 minutes. The miles will add up quickly.

In addition to the mental acuity benefits, this may also help with your psychological health, giving you a mental break from endless Zoom calls and your eyes a break from endless screens.

If you ratchet up the exercise to running, a study showed that mood also improves, mollifying anger (3). The act of running actually increases your serotonin levels, a hormone that, when low, can make people agitated or angry. So, exercise may actually help you get your aggressions out.

Walking has other benefits as well. We’ve all heard about the importance of doing weight-bearing exercise to prevent osteoporosis and osteoporotic fractures. The movie “WALL-E” even did a spoof on this, projecting a future where people lived in their movable recliners. The result was a human skeletal structure that had receded over the generations from lack of use. Although it was tongue-in-cheek, it wasn’t too far from the truth; if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles.

So, remember, use your feet to keep your mind sharp. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References:

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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.

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It is important to drink water prior to and during exercise to avoid heart palpitations. METRO photo
Consequences of mild dehydration are subdued mood, decreased concentration, fatigue and headaches

By David Dunaief, M.D.

Dr. David Dunaief

With this summer’s hottest days right around the corner, discussing dehydration is timely. Even air conditioning can be dehydrating.

Complications and symptoms of dehydration can be mild to severe, ranging from constipation, mood changes, headaches and heart palpitations to heat stroke, migraines and heart attacks.

Dehydration is simple to avoid, right? Not necessarily. We may be dehydrated before experiencing symptoms of thirst.

Headaches and migraines

Temperature is a potential trigger for headaches and migraine. As the temperature rises by intervals of 9 degrees, the risk for headache and migraines increases by eight percent (1). This study involved 7,054 participants from one emergency room site. Warmer temperatures can potentially reduce blood volume in the body, causing artery dilation and resulting in higher risk of headaches and migraines.

In another study, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (2). Headache intensity decreased as well. Anecdotally, I had a patient who experienced a potentially dehydration-induced migraine after playing sports in the sweltering heat of Florida. He had the classic aura and was treated with hydration, Tylenol and caffeine, which helped avoid much of the suffering.

Heart palpitations

It is important to drink water prior to and during exercise to avoid heart palpitations. METRO photo

Heart palpitations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise are contributing factors (3). They occur mainly when we don’t hydrate prior to exercise. All we need to do is drink one glass of water prior to exercise and then drink during exercise to avoid palpitations. Though these symptoms are not usually life-threatening, they are anxiety producing for patients.

Potential for heart attacks

The Adventist Health Study, an observational study, showed a dose-response curve for men (4). In other words, group one, which drank more than five glasses of water daily, had the least risk of death from heart disease than group two, which drank more than three glasses of water daily. Those in group three, which drank fewer than two glasses per day, saw the least amount of benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrinogen, a substance that helps clots form.

Mood and energy levels

In a study, mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women (5). In this small study the mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

I would also suggest, from my practice experience, hydration prior to exercise.

Ways to stay hydrated

Now we realize we need to stay hydrated, but how do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data, but did not find adequate studies to suggest that eight glasses is supported in the literature (6). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like Mediterranean or Dietary Approaches to Stop Hypertension (DASH), have a plant-rich focus. A study notes that diets with a focus on fruits and vegetables increases water consumption (7). As you may know, 95 percent of the weights of many fruits and vegetables are attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Is coffee dehydrating?

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (8). With moderate amounts of caffeinated beverages, the liquid has a more hydrating effect than its diuretic effect.

Thus, it is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (9).

References:

(1) Neurology. 2009 Mar 10;72(10):922-7. (2) Handb Clin Neurol. 2010;97:161-72. (3) my.clevelandclinic.org. (4) Am J Epidemiol 2002 May 1; 155:827-33. (5) J. Nutr. February 2012 142: 382-388. (6) AJP – Regu Physiol. 2002;283:R993-R1004.  (7) Am J Lifestyle Med. 2011;5(4):316-319. (8) Exerc Sport Sci Rev. 2007;35(3):135-140. (9) Br J Ophthalmol. 2005:89:1298–1301.

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.

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Nail fungus usually affects toenails. METRO photo
Treating nail fungus requires patience

By David Dunaief, M.D.

Dr. David Dunaief

As we begin our forays into summer public spaces, we are also beginning to expose our toes at the beach and in strappy sandals. Some are more self-conscious about it because of a disease called onychomycosis, better known as nail fungus.

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

Many consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is also an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat, although it affects approximately eight percent of the population (2). The risk factors are unclear but may relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected (3).

Many organisms can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A potassium hydroxide (KOH) preparation can be used to differentiate them. This is important, because some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of psoriasis.

When considering treatment, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most effective, but they also have the most side effects. The treatments can take from around three months to one year. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Oral treatments

There are several oral antifungal options, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These tend to have the greatest success rate, but the disadvantages are their side effects. In a small but randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of toenail fungus with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration. Patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with the 24-week group experiencing better results.

The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked regularly while using terbinafine.

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

Topical options

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

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). In a small study of 56 patients comparing laser only with laser plus topical antifungals, the best complete “cure” rates were achieved with the combination therapy, 21 percent versus 11 percent with laser only (10).

The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Partial improvement occurred in the toenails of 10 patients. The gel was applied daily for 48 weeks. The advantages are low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and a lower efficacy when compared to oral antifungals.

None of the treatments are perfect. Oral medications tend to be the most efficacious but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance.

If you decide on this approach, discuss it with your doctor and comply with precautionary tests on a regular basis, such as liver enzyme monitoring. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better choice. No matter what, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196; Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Eur J Med Res. 2018; 23: 53. (11) J Am Board Fam Med. 2011;24:69–74.

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.

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Focus on improving your health by making lifestyle modifications. METRO photo
The right motivators might be as important as dietary changes

By David Dunaief, M.D.

Excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis, autoimmune diseases and a host of others. Weight also has an impact on all-cause mortality and longevity.

In theory, losing weight should be simple: if we burn more kilocalories (energy) than we take in, we should lose weight. However, it is much more complicated.

Among factors that result in weight loss (or not) are stress levels. High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone (1). In this case, hormones contribute to weight gain.

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

But the debate continues as to which diet is best – for both weight loss and overall health. Let’s look at the evidence.

Low-carbohydrate vs. low-fat diets

Is a low-carbohydrate, high-fat diet a fad? In the publication of a 12-month randomized controlled trial (RCT), results showed that a low-carbohydrate diet was significantly better at reducing weight than low-fat diet, by a mean difference of 3.5 kg lost (7.7 lb), even though calories were similar and exercise did not change (2).

The authors also note that the low-carbohydrate diet reduced cardiovascular disease risk factors in the lipid (cholesterol) profile, such as decreasing triglycerides (mean difference 14.1 mg/dl) and increasing HDL (good cholesterol). Patients lost 1.5 percent more body fat on the low-carbohydrate diet, and there was a significant reduction in the inflammation biomarker C-reactive protein (CRP). There was also a reduction in the 10-year Framingham risk score, which estimates cardiovascular risk. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group.

There were 148 participants, predominantly women with a mean age of 47, none of whom had cardiovascular disease or diabetes, but all of whom were obese or morbidly obese (BMI 30-45 kg/m²). Although there were changes in biomarkers, there was a dearth of cardiovascular disease clinical end points, which were not investigated.

Digging deeper into the diets used, it’s interesting to note that the low-fat diet was remarkably similar to the standard American diet; it allowed 30 percent fat, only 5 percent less than the 35 percent baseline for the same group. In addition, it replaced the fat with mostly refined carbohydrates, including only 15 to 16 g/day of fiber.

The low-carbohydrate diet participants took in an average of 100 fewer calories per day than participants on the low-fat diet, so it’s no surprise that they lost a few more pounds over a year’s time.

As David Katz, M.D., founding director of Yale University’s Prevention Research Center, noted, this study was more of a comparison of low-carbohydrate diet to a high-carbohydrate diet than a comparison of a low-carbohydrate diet to a low-fat diet (3).

Diet comparisons

Interestingly, in a meta-analysis (group of 48 RCTs), results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet) was followed, there was a similar amount of weight loss compared to no intervention at all (4). Both diet types resulted in about 8 kg (17.6 lb) of weight loss at six months versus no change in diet.

In an accompanying editorial, the author points out that it is unclear whether a low-carbohydrate/high-animal protein diet might result in adverse effects on the kidneys, loss of calcium from the bones, or other potential health risks. The author goes on to say that, for overall health and longevity and not just weight loss, micronutrients found in nutrient-dense foods may be the most important factor.

A Seventh-Day Adventist trial would attest to the benefits of emphasizing a micronutrient-rich, plant-based diet with limited animal protein. It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet (5).

Psyche

Finally, the type of motivator is important, whatever our endeavors. Weight loss goals are no exception. A published study followed West Point cadets from school to many years after graduation and noted who reached their goals (6). The researchers found that internal motivators and instrumental (external) motivators were very important.

The soldiers who had an internal motivator, such as wanting to be a good soldier, were more successful than those who focused on instrumental motivators, such as wanting to become a general. Those who had both internal and instrumental motivators were not as successful as those with internal motivators alone. In other words, having internal motivators led to an instrumental consequence of advancing their careers.

When it comes to health, focusing on an internal motivator, such as increasing energy or decreasing pain, could ultimately lead to an instrumental consequence of weight loss.

There is no question that dietary changes are most important to achieving sustained weight loss. However, we need to get our psyches in line for change. Hopefully, when we choose to improve our health, we don’t just focus on weight as a measure of success. Focus on improving your health by making lifestyle modifications. This tends to result in a successful instrumental consequence.

References:

(1) Psychoneuroendocrinol. online 2014 April 12. (2) Ann Intern Med. 2014;161(5):309-318. (3) Huffington Post. Sept 2, 2014. (4) JAMA. 2014;312(9):923-933. (5) JAMA Intern Med. 2013;173:1230-1238. (6) Proc Natl Acad Sci U S A. 2014;111(30):10990-10995.

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.

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