Medical Compass

The American Cancer Society recommends women 45-54 get annual screenings. METRO photo
New research on bisphosphonates helps clarify their role in prevention

By David Dunaief, M.D.

Dr. David Dunaief

Breast cancer is the most common cancer diagnosed in U.S. women. Experts estimate that 30 percent of 2022 cancer diagnoses in women will be breast cancer (1). Only 15 percent of cases occur in those who have a family history of the disease, and 85 percent of new diagnoses will be invasive breast cancer.

A primary objective of raising awareness during October is to promote screening for early detection. Screening is crucial, but it is not prevention, which is just as important. Prevention strategies should include primary prevention, preventing the disease from occurring by lowering your risk, and secondary prevention, preventing breast cancer recurrence.

Here, we will discuss current screening recommendations, along with tools to lower your risk.

What are current screening recommendations?

There is some variation in screening guidelines; experts don’t agree on age and frequency. The U.S. Preventive Services Task Force currently recommends mammograms every other year, from age 50 through age 74, with the option of beginning as early as age 40 for those with significant risk (2). These 2016 guidelines are currently undergoing a review and are pending publication.

The American College of Obstetricians and Gynecologists encourages a process of shared decision-making between patient and physician to determine age and frequency of exams, including whether to begin exams before age 50 or to continue after age 75 (3). Generally, it recommends beginning annual or biennial mammograms starting no later than 50 and continuing until age 75. 

The American Cancer Society’s physician guidelines are to offer a mammogram beginning at age 40 and recommend annual exams from 45 to 54, with biennial exams after 55 until life expectancy is less than 10 years (4).

It is important to consult with your physician to identify your risk profile and plan or revise your regular screening schedule accordingly.

When do bisphosphonates help?

Bisphosphonates, which include Fosamax (alendronate), Zometa (zoledronic acid) and Boniva (ibandronate), are used to treat osteoporosis. Do they have a role in breast cancer risk prevention? The short answer: it may help prevent recurrence but doesn’t appear to provide primary protective benefits.

In a meta-analysis involving two randomized controlled trials (RCTs), FIT and HORIZON-PFT, results showed no benefit from the use of bisphosphonates in reducing breast cancer risk (5). The study population involved 14,000 postmenopausal women from ages 55 to 89 women who had osteoporosis, but who did not have a personal history of breast cancer. In other words, bisphosphonates were being used for primary prevention.

However, it does appear that bisphosphonates have a role in preventing breast cancer recurrence. The recent SUCCESS A phase 3 trial considered the optimal time for treatment. Findings published in 2021 indicate that two years of treatment for patients with high-risk early breast cancer reduced recurrence risk as much as five years of treatment (6). This could alter the current paradigm of 3-to-five years of treatment to prevent recurrence of certain types of breast cancer, reducing incidences of troublesome side effects.

A Lancet metanalysis focused on breast cancer recurrence in distant locations, including bone, and survival outcomes did find benefits for postmenopausal women (7). A good synopsis of the research can be found at

What’s the role of exercise?

We know exercise is important in diseases and breast cancer is no exception. In an observational trial, exercise reduced breast cancer risk in postmenopausal women significantly (8). These women exercised moderately; they walked four hours a week over a four-year period. If they exercised previously, five to nine years ago, but not recently, no benefit was seen. The researchers stressed that it is never too late to begin exercise. Only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. We need to expend as much energy and resources emphasizing exercise for prevention as we do screenings.

What about soy?

Contrary to popular belief, soy may be beneficial in reducing breast cancer risk. In a meta-analysis, those who consumed more soy saw a significant reduction in breast cancer compared to those who consumed less (9). There was a dose-response curve among three groups: high intake of >20 mg per day, moderate intake of 10 mg and low intake of <5 mg. Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk when compared to those who consumed the least. In addition, higher soy intake has been associated with reduced recurrence and increased survival for those previously diagnosed with breast cancer (10). The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

Hooray for Breast Cancer Awareness Month stressing the importance of mammography and breast self-exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a Mediterranean diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence.


(1) (2) (3) (4) (5) JAMA Intern Med. 2014;174(10):1550-1557. (6) JAMA Oncol. 2021;7(8):1149–1157. (7) Lancet. 2015 Jul 23. (8) Cancer Epidemiol Biomarkers Prev. 2014 Sep;23(9):1893-902. (9) Br J Cancer. 2008; 98:9-14. (10) JAMA. 2009 Dec 9; 302(22): 2437–2443.

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

Eczema is more common in women than it is in men. METRO photo
Treatments are continually evolving

By David Dunaief, M.D.

Dr. David Dunaief

The causes of eczema are unknown, but it is thought that nature and nurture are both at play (1). Essentially, it is a chronic inflammatory process that involves symptoms of rashes, itching, pain and redness (2).

It’s estimated that over seven percent of the U.S. adult population suffers from eczema (3), with twice as many females as males affected (4).

While there is no cure, there are treatments its symptoms. These range from over-the-counter creams and lotions to prescription steroid creams to oral steroids and injectable biologics. Antihistamines can also be used to treat itchiness. Some use phototherapy for severe cases, but research on its effectiveness is scant. Interestingly, lifestyle, specifically diet, may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

Let’s look at the evidence.

Does diet play a role?

Eczema is more common in women than it is in men. METRO photo

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (5).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (6).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15 to 20 percent of patients who suffer some level of eczema. For example, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin significantly improved.

What about supplements?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective – and with some important concerns.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (7). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (8).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.


Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (9). There are two currently approved by the FDA, dupilumab and tralokinumab-ldrm, with the latter recently approved in December 2021.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like any drug therapy, it does have side effects.

Deeper impacts of eczema

Eczema may be related to broken bones, according to several studies. For example, one observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more disturbing 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (10).

And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that the use of corticosteroids in treatment could be one reason for increased fracture risk, in addition to chronic inflammation, which may also contribute to the risk of bone loss.

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A recently published study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (11). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (12). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroid use, because of the long-term side effects. Lifestyle modifications appear to be very effective, at least at the anecdotal level.


(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) (3) J Inv Dermatol. 2017;137(1):26-30. (4) BMC Dermatol. 2013;13(14). (5) Allergy. 2010 Jun 1;65(6):758-765. (6) J Am Acad Dermatol. 2004;50(3):391-404. (7) Cochrane Database Syst Rev. 2013;4:CD004416. (8) (9) (9) JAMA Dermatol. 2015;151(1):33-41. (10) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (11) (12) Contact Dermatitis 2008; 59:43-47.

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

5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular and all-cause mortality. METRO photo
Modest lifestyle changes can add quality years

By David Dunaief, M.D.

Dr. David Dunaief

This past Monday, Canada honored the life of Queen Elizabeth II. Among other tributes, there was a 96-shot salute, with one shot for each year of her life. As you might imagine, it took a while.

While living to 96 was once unusual, it’s becoming more common. According to the National Institutes of Health, those in the U.S. who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those aged 85 and older.

What do these people have in common? According to one study, they tend to have fewer chronic morbidities or diseases. Thus, they tend to have a better quality of life with greater physical functioning and mental acuity (2).

In a study of centenarians, genetics played a significant role. Characteristics of this group were that they tended to be healthy and then die rapidly, without prolonged suffering (3). In other words, they grew old “gracefully,” staying mobile and mentally alert.

Factors that predict one’s ability to reach this exclusive club may involve both genetics and lifestyle choices. Let’s look at the research.

Get at least modest exercise

We are told repeatedly to exercise. Here’s one reason. Results of one study showed that 5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular and all-cause mortality (4).

Amazingly, even if participants ran fewer than six miles per week at a pace slower than 10-minute miles, and even if they ran only one to two days a week, there was still a decrease in mortality compared to nonrunners. Those who ran for this very short amount of time potentially added three years to their life span. There were 55,137 participants ranging in age from 18 to 100 years old.

An accompanying editorial to this study noted that more than 50 percent of people in the United States do not meet the current recommendation of at least 30 minutes of moderate exercise per day (5).

A study presented this past August at the European Society of Cardiology Congress looked at the role of simple physical activity in the elderly (6). It found that those 85 and older reduced the risk of all-cause mortality 40 percent by walking just 60 minutes a week. This is physical activity that does not actually qualify as exercise.

Eat less animal protein

A long-standing paradigm has been that we need to eat sufficient animal protein. However, cracks have developed in this theory, especially as it relates to longevity.

In an observational study using NHANES III data, results show that those who ate a high-protein diet (greater than 20 percent of calories from protein) had a twofold increased risk of all-cause mortality, a four-times increased risk of cancer mortality, and a four-times increased risk of dying from diabetes (7). This was over a considerable duration of 18 years and involved almost 7,000 participants ranging in age at the start of the study from 50 to 65.

However, this did not hold true if the protein source was plants. In fact, a high-protein plant diet may reduce the risks, not increase them. The reason, according to the authors, is that animal protein may increase insulin growth factor-1 and growth hormones that have detrimental effects on the body.

The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein once a week or less had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (8). This was an observational trial with over 73,000 participants and a median age of 57 years old.

Reduce systemic inflammation

In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ longevity (9). In fact, if participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.

The good news is that inflammation can be improved significantly with lifestyle changes.

The takeaway from this study is that IL-6 is a relatively common biomarker for inflammation. It can be measured with a simple blood test offered by most major laboratories. This study involved 3,044 participants over the age of 35 who did not have a stroke, heart attack or cancer at the beginning of the study.

The bottom line is that, although genetics are important for longevity, so too are lifestyle choices. A small amount of exercise and replacing animal protein with plant protein can contribute to a substantial increase in healthy life span. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Therefore, why not have a discussion with your doctor about testing to see if you have an elevated IL-6? Lifestyle modifications may be able to reduce these levels.


(1) (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) J Am Coll Cardiol. 2014;64:472-481. (5) J Am Coll Cardiol. 2014;64:482-484. (6) European Society of Cardiology Congress, Aug. 28, 2022. (7) Cell Metab. 2014;19:407-417. (8) JAMA Intern Med. 2013;173:1230-1238. (9) CMAJ. 2013;185:E763-E770.

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

Diabetes. METRO Photo
In some patients, small amounts of wine may reduce cardiovascular risks

By David Dunaief, M.D.

Dr. David Dunaief

Our understanding of diabetes — its risks and treatment paradigms — is continually evolving and improving. This is good news, since the current rate of diabetes among the U.S. adult population is 13 percent, while another estimated 88 million U.S. adults have prediabetes (1).

What is prediabetes? Typically, it’s when fasting glucose levels (HbA1C) sit in the 5.7 and 6.4 percent range.

With diabetes comes a host of other health complications, including increased heart attack risk. However, cardiovascular risk and its severity may not equally affect men and women. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a higher rate than men, although both had substantial risk increases, 162 percent and 96 percent, respectively (2).

What might reduce our risks for diabetes or its complications? Fortunately, we have options. These include diet improvements, timing of blood pressure medications, and, oddly, modest wine consumption.

Diet bests metformin for diabetes prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is a disservice; lifestyle changes may be more effective in preventing this disease.

In a head-to-head comparison study, diet plus exercise outperformed metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: one received a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; one took metformin 875 mg twice a day; and one was a placebo group. Diet and exercise reduced diabetes risk by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, the diet they used was not an optimal diabetes diet.

Blood pressure medications’ timing

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (4). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of diabetes risk than morning blood pressure or 48-hour ambulatory blood pressure. This study had a long duration of almost six years with about 2,000 participants.

Researchers used three blood pressure medications in the trial: ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers.

The first two have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, these had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes.

Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.

Can wine help?

Diabetes patients are often warned to limit or eliminate alcohol. A significant part of the reasoning relates to how the body metabolizes alcohol and sugars. So, the results of a study that showed small amounts of wine could have benefits in reducing diabetes-associated complications among those whose sugars were well-controlled sent ripples throughout the medical community.

The CASCADE trial, a randomized controlled trial, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (5).

Patients were randomized into three groups, each receiving a drink with dinner nightly. One group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily. This was a small study, and participants were well-controlled type 2 diabetes patients who generally were nondrinkers.

We need to reverse the trend toward higher diabetes prevalence. The good news is that we’re continuing to learn what lowers diabetes risk and, for those with Type 2 diabetes, what can improve cardiovascular risks.


(1) (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Diabetologia. Online Sept. 23, 2015. (5) Ann Intern Med. 2015;163(8):569-579.

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

Stock photo
Antioxidant diet may improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. Unlike a heart attack, which is acute, heart failure develops slowly and may take years to become symptomatic.

There are two types of heart failure, systolic and diastolic. The basic difference is that the ejection fraction, the output of blood with each contraction of the left ventricle of the heart, is more or less preserved in diastolic HF, while it can be significantly reduced in systolic HF.

We have more medical research on systolic heart failure. Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue.

Major lifestyle risk factors for heart failure include obesity; smoking; poor diet, including consuming too much sodium; being sedentary; and drinking alcohol excessively. Conditions that increase your risk include diabetes, coronary artery disease and high blood pressure.

Typically, heart failure is treated with blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. We are going to look at how diet and iron levels can affect heart failure outcomes.

Increasing antioxidants in the diet

If we look beyond the usual risk factors mentioned above, oxidative stress may play an important role as a contributor to HF.

In a population-based, prospective study, the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (1). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

What makes this study so impressive is that it is the first of its kind to investigate antioxidants from the diet and their impacts on heart failure prevention.

This was a large study, involving 33,713 women, with good duration — follow-up was 11.3 years. There are limitations to this study, because it is observational and the population involved only women. Still, the results are very exciting, and it is unlikely there is a downside to applying this approach to the population at large.

Addressing iron deficiencies

An observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (2).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L. The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients.

These studies suggest that we should try to prevent heart failure through dietary changes, including high levels of antioxidants, because it is not easy to reverse the disease. Those with HF should have their ferritin and iron levels checked, because these can be addressed with medical supervision.


(1) Am J Med. 2013 Jun:126(6):494-500. (2) Am Heart J. 2013;165(4):575-582.

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

Pixabay photo
Simple changes can help you improve lung function

By David Dunaief, M.D.

Dr. David Dunaief

As we are learning to live alongside COVID-19, we also have a heightened awareness of the importance of strong lung function. For those with chronic obstructive lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma, as well as those who smoke and vape, the consequences of COVID-19 are especially severe.

The good news is that we can improve lung function with simple lifestyle modifications including exercising, eating a plant-based diet with a focus on fruits and vegetables, expanding lung capacity with an incentive spirometer, and quitting smoking and vaping, which damage the lungs (1). Not only people with compromised lungs will benefit from these techniques, studies suggest everyone will benefit.

Improving asthma

In a randomized controlled trial of asthma patients, results show that after 14 days those who ate a high-antioxidant diet had greater lung function than those who ate a low-antioxidant diet (2). Additionally, those who were in the low-antioxidant diet group also had higher inflammation at 14 weeks. Inflammation was measured using a c-reactive protein (CRP) biomarker. Those who were in the low-antioxidant group also were over two-times more likely to have an asthma exacerbation. 

The good news is that the difference in behavior between the high- and low-antioxidant groups was small. The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Carotenoid supplementation, instead of antioxidant foods, made no difference in inflammation. The authors concluded that an increase in carotenoids from diet has a clinically significant impact on asthma and can be seen in a very short period. 

Focusing on COPD

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers. Bear with me, because the studies were done with men or women, not both at the same time.

In one study of men, for example, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (3). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain, essentially a whole foods plant-based diet. The high-fiber group was still below the American Dietetic Association-recommended 38 grams per day. This is within our grasp. 

In another study, women had a highly significant 37 percent decreased risk of COPD among those who consumed at least 2.5 serving of fruit per day compared to those who consumed less than 0.8 servings per day (4).

The highlighted fruits shown to reduce COPD in both men and women included apples, bananas, and pears.

Using incentive spirometry

An incentive spirometer is a device that helps expand the lungs by inhaling through a tube and causing a ball or multiple balls to rise in a tube. This action opens the alveoli and may help you breathe better. 

Incentive spirometry has been used for patients with pneumonia, those who have chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (5). A small study showed that those who trained with an incentive spirometer for two weeks increased their vital capacity, right and left chest wall motion, and right diaphragm motion. This means it improved lung function and respiratory motion. Participants were 10 non-smoking healthy adults who were instructed to take five sets of five deep breaths twice a day, totaling 50 deep breaths per day. The brands used in the study are inexpensive and easily accessible, such as Teleflex’s Triflo II.

In another small, two-month study of 27 patients with COPD, the incentive spirometer improved blood gases, such as partial pressure carbon dioxide and oxygen, in COPD patients with exacerbation (6). The authors concluded that it may improve quality of life for COPD patients.  

Increasing exercise

Exercise can have a direct impact on lung function. In a study involving healthy women ages 65 years and older, results showed that 20 minutes of high-intensity exercise three times a day improved FEV1 and FVC, both indicators of lung function, in as little as 12 weeks (7). Participants began with a 15-minute warm-up, then 20 minutes of high-intensity exercise on a treadmill, followed by 15 minutes of cool-down with stretching.

What is impressive is that it was done in older adults, not those in their twenties and not in elite athletes.

Note that you don’t need a treadmill to do aerobic exercise. You can walk up steps or steep hills in your neighborhood, do jumping jacks, or even dance in your living room. Whatever you choose, you want to increase your heart rate and expand your lungs. If this is new for you, consult a physician and start slowly. You’ll find that your stamina improves rather quickly with consistency.

We all should be working to strengthen our lungs. This three-pronged approach of lifestyle modifications – diet, exercise and incentive spirometer – can help without expending significant time or expense.


(1) Public Health Rep. 2011 Mar-Apr; 126(2): 158-159. (2) Am J Clin Nutr. 2012 Sep;96(3):534-43. (3) Epidemiology Mar 2018;29(2):254-260. (4) Int J Epidemiol Dec 1 2018;47(6);1897-1909. (5) Ann Rehabil Med. Jun 2015;39(3):360-365. (6) Respirology. Jun 2005;10(3):349-53. (7) J Phys Ther Sci. Aug 2017;29(8):1454-1457. 

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

Metro photo
Consequences can be greater than snoring and fatigue

By David Dunaief, M.D.

Dr. David Dunaief

Good sleep contributes to our physical and mental wellbeing, however many of us struggle to get quality, restful sleep. For those with obstructive sleep apnea (OSA), quality sleep is especially elusive.

Sleep apnea is an abnormal pause in breathing that occurs at least five times an hour while sleeping. It can have an array of causes, the most common of which is airway obstruction. Some estimates suggest that about 30 million people suffer from sleep apnea in the United States (1).

Obstructive sleep apnea (OSA), also known as sleep-disordered breathing, may affect up to 30 percent of adults. OSA diagnoses are classified as either mild, moderate or severe. It’s estimated that roughly 80 percent of moderate and severe OSA sufferers are undiagnosed.

Risk factors for OSA include chronic nasal congestion, large neck circumference, excess weight or obesity, alcohol use, smoking and a family history (2). Many of these factors, however, are modifiable.

Significant symptoms of OSA tend to be quality of life issues and include daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration and morning headaches. While these are significant, it’s more concerning that OSA is also associated with an array of more serious health consequences, such as cardiovascular disease, high blood pressure and depression.

Fortunately, we have an arsenal of treatment options, including continuous positive airway pressure (CPAP) devices; oral appliances; lifestyle modifications, such as diet, exercise, smoking cessation and reduced alcohol intake; and some medications.

What is the impact on cardiovascular disease risk?

In an observational study, the risk of cardiovascular mortality increased in a linear fashion with the severity of OSA (3). For those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death; for those in the severe group, this risk jumped considerably to 250 percent. However, the good news is that treating patients with CPAP considerably decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients. This study involved 1,116 women over a six-year duration.

Another observational study with male subjects showed similar risks of cardiovascular disease with sleep apnea and benefits from CPAP treatment (4). There were more than 1,500 men in this study with a 10-year follow-up. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in curbing these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA by 38 and 125 percent, respectively (5). But, as in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

Is there a cancer connection?

In sleep apnea patients under age 65, a study showed an increased risk of cancer (6). The authors believe that intermittent low levels of oxygen, caused by the many frequent short bouts of breathing cessation, may be responsible for the development of tumors and their subsequent growth.

The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. For those patients with more than 12 percent low-oxygen levels at night, there was a twofold increased risk of cancer development when compared to those with less than 1.2 percent low-oxygen levels.

Does OSA affect male sexual function?

It appears that erectile dysfunction (ED) may also be associated with OSA. CPAP may decrease this incidence. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspects of this study were that, at baseline, the participants were overweight, not obese, on average and were only 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

An array of other studies on the association between OSA and ED have varying results, depending on the age and existing health challenges of the participants. Some study authors have postulated that other underlying health problems may be the cause in some patient populations.

Can diet help?

For some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or it may be used in combination with CPAP to improve results.

In a small study of those with moderate-to-severe OSA levels, a low-energy diet showed positive results. A low-energy diet implies a low-calorie approach, such as a diet that is plant-based and nutrient-rich. It makes sense, this can help with weight loss. In the study, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year.

The bottom line is that if you think you or someone else is suffering from sleep apnea, it is important to be evaluated at a sleep lab and then follow up with your doctor. Don’t suffer from sleep apnea and, more importantly, don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are many effective treatments.


(1) (2) JAMA. 2004;291(16):2013. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) Am J Respir Crit Care Med. 2012 Nov. 15. (7) Sleep. 2012;35:A0574. (8) BMJ. 2011;342:d3017.

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

Pixabay photo
Different dietary approaches may help modulate the immune system

By Dr. David Dunaief

Dr. David Dunaief

Autoimmune disease is when the body’s immune system attacks the organs, cells and tissues and causes chronic inflammation. However, this umbrella term refers to more than 80 different diseases (1). Some are familiar names, like type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, multiple sclerosis, and inflammatory bowel disease. Others, like Lambert-Eaton myasthenic syndrome and Cogan syndrome, are less well-known.

Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others. They disproportionately affect women, although men are also at risk.

Treating autoimmune diseases with meds

The primary treatment is immunosuppressives. In RA, for example, where there is swelling of joints bilaterally, a typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

However, there are several concerning factors with these drugs. First, the side-effect profiles are substantial. They includes risks of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning required by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

It is no surprise that suppressing the immune system would increase the likelihood of infections. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term clinical trials; however, many patients are prescribed these therapies for 20 or more years.

So, what other methods are available to treat autoimmune diseases? Medical nutrition therapy using bioactive compounds and supplementation are being studied. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

Managing inflammation with nutrition

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including c-reactive protein (CRP), and improvements in joint pain and other quality of life concerns.

Fish oil’s effects

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). A typical recommendation is to consume about 2 grams of EPA plus DHA to help regulate the immune system. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood-thinning effects.

Probiotic supplements

Approximately 70 percent of your immune system lives in your gut. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Increasing fiber intake

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and, potentially, autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high-nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects, treating and preventing autoimmune diseases.


(1) (2) J Autoimmun. 2007;29(1):1. (3) (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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

Many people suffer from IBS.
Fructose, lactose and gluten may be contributors

By David Dunaief, MD

Dr. David Dunaief

If you suffer from irritable bowel syndrome (IBS), its symptoms can directly affect your quality of life. They include abdominal pain, cramping, bloating, constipation and/or diarrhea.

According to estimates, 10 to 15 percent of the population suffers from IBS symptoms, although only five to seven percent have been diagnosed (1).

Diagnosing IBS is challenging. While the general perception is that IBS symptoms are somewhat vague, there are discrete criteria physicians use to provide a diagnosis it and eliminate more serious possibilities.

The Rome IV criteria comprise an international effort to help diagnose and treat functional gastrointestinal disorders. Using these criteria, which include frequency of pain and discomfort over the past three months, in combination with a physical exam helps provide a diagnosis.

So, what can be done to improve symptoms? There are a number of possibilities that require only modest lifestyle changes.

Addressing your mental state

The “brain-gut” connection refers to the direct connection between mental state, such as nervousness or anxiety, to gastrointestinal issues, and vice versa.

Mindfulness-based stress reduction was used in a small, but randomized, eight-week clinical trial with IBS (2). Those in the mindfulness group (treatment group) showed statistically significant results in decreased severity of symptoms compared to the control group, both immediately after training and three months post-therapy.

Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.

Possible link with migraines

A preliminary study has suggested there may be a link between IBS and migraine and tension-type headaches. The study of 320 participants, 107 with migraine, 107 with IBS, 53 with episodic tension-type headaches (ETTH), and 53 healthy individuals, identified significant occurrence crossover among those with migraine, IBS and ETTH. Researchers also found that these three groups had at least one gene that was different from that of healthy participants. Their hope is that this information will lead to more robust studies that could result in new treatment options (3).

Gluten consumption a factor?

In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo, 68 percent vs. 40 percent, respectively (4). These results were highly statistically significant. The authors concluded that nonceliac gluten intolerance may exist. Gluten sensitivity may be an important factor in for some IBS patients (5). I suggest to my patients that they might want to start avoiding gluten and then add it back into their diets slowly to see the results.

What about fructose?

Some IBS patients may suffer from fructose intolerance. In a study, IBS researchers used a breath test to examine this possibility (6). The results were dose-dependent, meaning the higher the dose of fructose, the greater the effect researchers saw. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.

The symptoms of fructose intolerance included gas, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that avoidance of fructose may reduce symptoms in IBS patients.

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (7). Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.

Considering the effects of lactose

Another small study found that about one-quarter of patients with IBS also have lactose intolerance. Two complications are at play here. One, it is very difficult to differentiate the symptoms of lactose intolerance from IBS. The other is that most IBS trials are small and there is a need for larger trials. Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptomatology at both six weeks and five years when placed on a lactose-restricted diet (8).

Though the trial was small, the results were statistically significant, which is impressive. Both the patient compliance and long-term effects were excellent, and visits to outpatient clinics were reduced by 75 percent. This demonstrates that it is probably worthwhile to test patients who have IBS symptoms for lactose intolerance.

Are probiotics part of the solution?

Treatment with probiotics from a study that reviewed 42 trials shows that there may be a benefit to probiotics, although the endpoints, or objectives, were different in each trial. The good news is that most of the trials reached one of their endpoints (9). Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.

All of the above provides hope for IBS patients. These are treatment options that involve modest lifestyle changes. I believe there needs to be a strong patient-doctor connection in order to select an approach that results in the greatest symptom reduction for a specific patient.


(1) American College of Gastroenterology []. (2) Am J Gastroenterol. 2011 Sep;106(9):1678-1688. (3) American Academy of Neurology 2016, Abstract 3367. (4) Am J Gastroenterol. 2011 Mar;106(3):508-514. (5) Am J Gastroenterol. 2011 Mar;106(3):516-518. (6) Am J Gastroenterol. 2003 June;98(6):1348-1353. (7) J Clin Gastroenterol. 2008 Mar;42(3):233-238. (8) Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944. (9) Aliment Pharmacol Ther. 2012 Feb;35(4):403-413.

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

Vitamin D. Pixabay photo
Cumulative impact of lifestyle changes can be significant

By David Dunaief, M.D.

Dr. David Dunaief

Most often associated with tremors and other movement disorders, Parkinson’s disease is a neurodegenerative disorder. Roughly 60,000 are diagnosed with Parkinson’s disease (PD) annually in the U.S., and approximately one million Americans are living with PD (1).

Patients with PD suffer from a collection of symptoms caused by the breakdown of brain neurons. In medicine, we know the most common symptoms by the mnemonic TRAP: tremors while resting, rigidity, akinesia/bradykinesia (inability/difficulty to move or slow movements) and postural instability or balance issues. It can also result in a masked face, one that has become expressionless, and potentially dementia.

There are several different subtypes of PD; the diffuse/malignant phenotype has the highest propensity for cognitive decline (2).

There’s a lot we still don’t know about the causes of PD; however, risk factors may include head trauma, genetics, exposure to toxins and heavy metals, and lifestyle issues, like lack of exercise.

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (3). Adding back dopamine has been the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also with lifestyle modifications. Lifestyle factors include iron, vitamin D and CoQ10. The research, unfortunately, is not conclusive, though it is intriguing.

Impact of iron in the brain

This heavy metal is potentially harmful for neurodegenerative diseases such as Alzheimer’s disease, macular degeneration, multiple sclerosis and, yes, Parkinson’s disease. The problem is that this heavy metal can cause oxidative damage.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (4). This drug was mostly well-tolerated.

The chelator reduced the risk of disease progression significantly on the Unified Parkinson Disease Rating Scale (UPDRS) during the 12-month study. Participants who were treated sooner had lower levels of iron compared to a group that used the chelator six months later. A specialized MRI was used to measure levels of iron in the brain.

The iron chelator does not affect, nor should it affect, systemic levels of iron, only those in the brain specifically focused on the substantia nigra region. The chelator may work by preventing degradation of the dopamine-containing neurons. It also may be recommended that you consume foods that contain less iron.

Does CoQ10 help?

When we typically think of using CoQ10, a coenzyme found in over-the-counter supplements, it is to compensate for depletion from statin drugs or due to heart failure. Typical doses range from 100 to 300 mg. However, there is evidence that CoQ10 may be beneficial in Parkinson’s at much higher doses.

In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to the placebo group (5). Other doses of 300 and 600 mg showed trends toward benefit, but were not significant. This was a 16-month trial in a small population of 80 patients. Unfortunately, results for other CoQ10 studies have been mixed. In this study, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with PD.

Does Vitamin D make a difference?

In a prospective study, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (6). This is quite impressive, especially since the highest quartile patients had vitamin D levels that were what we would qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less. There were over 3,000 patients involved in this study with an age range of 50 to 79.

While many times we are deficient in vitamin D and have a disease, replacing the vitamin does nothing to help the disease. Here, it might. Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In an RCT, results showed that 1,200 IU of vitamin D taken daily may have reduced the progression of Parkinson’s disease significantly on the UPDRS compared to a placebo over a 12-month duration (7). Also, this amount of vitamin D increased the blood levels by almost two times from 22.5 to 41.7 ng/ml. There were 121 patients involved in this study with a mean age of 72.

In a 2019 study of 182 PD patients and 185 healthy control subjects, researchers found that higher serum vitamin D levels correlated to reduced falls and alleviation of other non-motor PD symptoms (8).

Vitamin D research is ongoing, as this all seems promising.

So, what have we learned? Though medication is the gold standard for Parkinson’s disease treatment, lifestyle modifications can have a significant impact on both prevention and treatment of this disease. Each lifestyle change in isolation may have modest effects, but cumulatively their impact could be significant.


(1) (2) JAMA Neurol. 2015;72:863-873. (3) (4) Antioxid Redox Signal. 2014;10;21(2):195-210. (5) Arch Neurol. 2002;59(10):1541-1550. (6) Arch Neurol. 2010;67(7):808-811. (7) Am J Clin Nutr. 2013;97(5):1004-1013. (8) Neurologica. 2019;140(4):274-280.

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