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Long-term PPI use increases serious risks. Stock photo
PPIs may increase your fracture risk

By David Dunaief, M.D.

Dr. David Dunaief

After a meal, do you sometimes have “reflux” or “heartburn?” Many of us experience these symptoms occasionally. When it happens more frequently, it could be a sign of gastroesophageal reflux disease (GERD).

Between 18.1 and 27.8 percent of U.S. adults have GERD, according to estimates; however, since many people self-treat with over-the-counter (OTC) medications, the real numbers could be higher (1).

If you take OTC proton pump inhibitors (PPIs), you could be among the uncounted. Familiar brands include Prilosec (omeprazole), Nexium (esomeprazole), and Prevacid (lansoprazole), among others. They are also available by prescription.

PPIs are not intended for long-term use, because of their robust potential side effects. Currently, the FDA suggests that OTC PPIs should be taken for no more than a 14-day treatment once every four months. Prescription PPIs should be taken for 4 to 8 weeks (2).

Unfortunately, many take them too long or too often, and some experience reflux rebound effects when they try to discontinue PPIs without physician oversight.

Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures, increased cardiac and vascular risks, vitamin malabsorption issues and Clostridium difficile (C. diff), a bacterial infection of the gastrointestinal tract.

PPIs can also interfere with other drugs you are taking, such as Plavix (clopidogrel).

PPIs and chronic kidney disease

Two separate studies showed that there was an increase in chronic kidney disease with prolonged PPI use (3). All patients started the study with normal kidney function, assessed by measuring glomerular filtration rate (GFR). The Atherosclerosis Risk in Communities (ARIC) study showed a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a 17 percent increased risk.

The medications were used on a chronic basis for years: the first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications and a milder drug class, H2 blockers (4).

PPIs and dementia risk

A German study looked at health records from a large public insurer and found a 44 percent increased risk of dementia in those aged 75 or older who were using PPIs, compared to those who were not (5). The authors surmise that PPIs may cross the blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower, 16 percent, increased risk.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. The research was not perfect, however. Researchers did not consider high blood pressure, excessive alcohol use or family history of dementia, all of which can influence dementia occurrence.

PPIs and fracture risk

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (6). With bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip, and any-site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (7).

PPIs and vitamin absorption

In addition to calcium absorption issues, PPIs may lower absorption of magnesium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (8). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

Another study’s results showed use of over two years increased vitamin B12 deficiency risk by 65 percent (9).

Takeaways

Before taking OTC PPIs, consult with your physician. A milder medication, such as an H2 blocker (Zantac, Pepcid), might be a better option.

Even better, start with lifestyle changes. Try to avoid eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, before you try medications (10).

If you do need medication, recognize that PPIs don’t provide immediate relief and should only be taken for a short duration to minimize their side effects.

References: 

(1) nih.gov. (2) fda.gov. (3) JAMA Intern Med. 2016;176(2). (4) JAMA Intern Med. 2016;176(2):172-174. (5) JAMA Neurol. online Feb 15, 2016. (6) Osteoporos Int. online Oct 13, 2015. (7) Am J Med. 118:778-781. (8) PLoS Med. 2014;11(9):e1001736. (9) Mayo Clinic Proceedings. 2018 Feb;93(2):240-246. (10) Am J Gastroenterol 2015; 110:393–400.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Deer ticks aka blacklegged ticks typically carry Lyme disease.METRO photo
The effects of Lyme disease can be debilitating

By David Dunaief, M.D.

Dr. David Dunaief

Warm weather is imminent and, if you’re like me, you’re looking forward to enjoying more time outside this summer.  

Summer’s arrival also means that tick season is in full swing, although “season” is becoming a misnomer when we refer to ticks. A June 16th New York Times article shared some of the challenges of changing tick behavior and the expansion of tick types and overlapping tick-borne diseases we’re now seeing in the Northeast (1).

The most common of these is Lyme disease, which is typically carried by deer ticks, also known as blacklegged ticks. Deer ticks can be as small as the period at the end of this sentence. The CDC site is a great resource for tick images and typical regions (2).

If a tick bites you, you should remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick; doing so may spread infectious disease (3). In a study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The National Institutes of Health recommends not removing a tick with oil (4).

When you remove a tick within 36 to 48 hours, your risk of infection is low. However, you can take a prophylactic dose of the antibiotic doxycycline within 72 hours of tick removal if you are not experiencing a bulls-eye rash — a red outer ring and red spot in the center (5). This can significantly lower your risk of developing Lyme disease, although doxycycline does sometimes cause nausea.

Know Lyme symptoms

The three stages of Lyme disease are: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue, muscle pain and joint pain, headache, neck stiffness, swollen glands, and fever (6).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory issues. Late disseminated disease can cause Lyme arthritis, heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (4).

Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death (7). If there are symptoms of chest pain, palpitations, light-headedness, shortness of breath or fainting, clinicians should suspect Lyme carditis.

Check for ticks 

The CDC suggests wearing protective clothing, using insect repellent with at least 20 percent DEET and treating your yard. Always check your skin and hair for ticks after spending time outside. Also, remember to check your pets; even if treated, they can carry ticks into the house.

Check for Lyme infection

Lyme disease often can be diagnosed within the clinical setting or with a blood test. However, testing immediately after being bitten by a tick is not useful. It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (6). These antibodies sometimes will remain elevated even after successful antibiotics treatment.

Remember that a single tick can transfer more than one disease, so you might need testing for other common tick-borne diseases, as well.

Monitor for post-Lyme effects

There is an ongoing debate about whether “chronic Lyme” disease exists. In one analysis of several prospective studies, researchers recognize that there are prolonged neurologic symptoms in a subset population that may be debilitating even after Lyme disease treatment (8). These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment. They note, however, that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes.

The lingering effects of Lyme can debilitate you and might be a result of systemic inflammation (9). Systemic inflammation and its symptoms can be improved significantly with dietary and other lifestyle modifications.

Prevention is key to helping stem Lyme and other tick-borne diseases. Become diligent about performing tick checks any time you’ve been outside. If you do find a tick, contact your physician immediately about prophylactic treatment.

References: 

(1) “The Tick Situation is Getting Worse. Here’s How to Protect Yourself.” New York Times. 16 June 2025. online. (2) https://www.cdc.gov/ticks/about/where-ticks-live.html. (3) Pediatrics. 1985;75(6):997. (4) nlm.nih.gov. (5) Clin Infect Dis. 2008;47(2):188. (6) uptodate.com. (7) MMWR. 2014;63(43):982-983. (8) Expert Rev Anti Infect Ther. 2011;9(7):787-797. (9) J Infect Dis. 2009;199(9:1379-1388).

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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METRO photo
Taking calcium may only help if you’re deficient

By David M. Dunaief, M.D.

Dr. David Dunaief

We should all be concerned about osteoporosis risk. According to the Bone Health & Osteoporosis Foundation, 50 percent of women and 25 percent of men will break at least one bone due to osteoporosis (1). Hip fractures are especially concerning, because they increase mortality risk dramatically. More than 50 percent of hip fracture survivors are no longer able to live independently (2).

Do we need to consume more dairy?

Studies suggest that milk and other dairy products may not be as beneficial as we have been raised to believe.

Studies have shown milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (3).

In a 2020 meta-analysis of several past studies, researchers concluded that increased consumption of milk and other dairy products did not lower osteoporosis and hip fracture risks (4).

Generally, studies suggest that dairy may cause additional health problems. The results of a large, 20-year, observational study involving men and women in Sweden showed that milk may be harmful (5). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. 

Dosage also mattered. For every one glass of milk consumed, there was a 15 percent increased risk of death for women. There was a much smaller, but significant, three percent per glass increased risk of death in men. For both women and men, researchers found biomarkers in the urine that indicated higher levels of oxidative stress and inflammation.

Remember: these are only associations, not decisive conclusions. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation.

Interestingly, the USDA recommends that, from the age of 9 through adulthood, we consume about three cups of dairy per day (6).

Should we take calcium supplements?

We know calcium is a required element for strong bones, but do supplements really prevent osteoporosis and subsequent fractures? While the data are mixed, it suggests supplements may not be the answer for those who are not calcium deficient.

In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food daily (7).

The researchers did not differentiate among the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In four clinical trials, the researchers saw an increase in hip fractures among those who took calcium supplements. A weakness of this large study is that vitamin D baseline levels, exercise and phosphate levels were not considered in the analysis.

Does vitamin D supplementation reduce risk?

Finally, though the data are not always consistent for vitamin D, it appears it may be valuable when it comes to fracture prevention. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in fewer fractures (8). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, those who were aged 65 and over experienced a 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures. However, vitamin D in lower levels did not significantly reduce fracture risk.

Where does that leave us?

Our knowledge of dietary approaches is continually evolving. Dairy’s role may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there was no significant benefit. However, the patients in these trials were not necessarily deficient in calcium nor vitamin D.

To prevent fracture, older patients may need at least 800 IUs of vitamin D supplementation per day.

Remember that treatment and prevention approaches should be individualized, and deficiencies in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References: 

(1) www.bonehealthandosteoporosis.org. (2) EndocrinePractice. 2020 May;26(supp 1):1-46. (3) JAMA Pediatr. 2014;168(1):54-60. (4) Crit Rev Food Sci Nutr. 2020;60(10):1722-1737. (5) BMJ 2014;349:g6015. (6) health.gov. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Fiber-rich foods, including whole grains, seeds and legumes, as well as some beverages, such as coffee and wine, contain measurable amounts of lignans. Stock photo
Ozempic/Mounjaro don’t substitute for lifestyle changes

By David Dunaief, M.D.

Dr. David Dunaief

Type 2 diabetes management knowledge is always evolving. Here, we will examine how some diabetes management myths hold up against recent research.

Myth: Fruit can raise your sugars

Diabetes patients are often advised to limit whole, juiced, and dried fruit, because it can raise your sugars. This is only partly true. 

Yes, you should avoid fruit juice and dried fruit, because they do raise or spike glucose (sugar) levels. This includes dates, raisins, and apple juice, which are often added to “no sugar” packaged foods to sweeten them.

This is not true for whole fruit, which can be fresh or frozen. Studies have shown that patients with diabetes don’t experience sugar level spikes from whole fruit, even when they consume them in abundance (1). Another study showed that consuming whole fruit reduces type 2 diabetes risk (2).

In a third study, researchers considered the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). The only fruit tested that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One reason for the beneficial effect is the fruits’ flavonoids, or plant micronutrients, but another is their fiber.

Myth: You should avoid all carbohydrates

Fiber is one type of carbohydrate that has important benefits. It can reduce risks for an array of diseases and improve outcomes. This holds true for type 2 diabetes risk. 

Two very large prospective observational studies, the Nurses’ Health Study (NHS) and NHS II, showed that plant fiber helped reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine when compared to the control group without diabetes. There was a direct relationship between the level of metabolites and the reduction in diabetes risk: the more they consumed and the more metabolites in their urine, the lower the risk. The authors encourage patients to eat a plant-based diet to get this benefit.

Foods with lignans include cruciferous vegetables, such as broccoli and cauliflower; an assortment of fruits and whole grains; flaxseed; and sesame seeds (5). The researchers could not determine which plants contributed the greatest benefit; however, they believe antioxidant activity drives this effect.

Myth: You should avoid soy

In diabetes patients with nephropathy (kidney damage or disease), consuming soy has been associated with kidney function improvements (6). There were significant reductions in urinary creatinine levels and proteinuria (protein in the urine), both signs that the kidneys are functioning better.

This was a four-year, small, randomized control trial with 41 participants. The control group’s diet included 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is important, since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism and low iodine levels should be cautious about soy consumption; some studies suggest it might interfere with synthetic thyroid medications’ effectiveness (8).

Myth: Ozempic/Mounjaro helps with weight loss

One of the latest entrants in diabetes sugar-control/weight loss pursuit is GLP-1 receptor agonists, including tirzepatide (Mounjaro/Zepbound) and semaglutide (Ozempic/Wegovy). They have a primary focus on glucose control and a secondary effect of weight loss. It sounds like a dream, right? Unfortunately, it’s not that simple. It’s important to recognize that the phase III clinical trial of these drugs’ weight loss capabilities actually excluded patients with diabetes (9). While the trials did measure lean body mass at different points and doses, they did not report muscle loss.

In clinical use since their approval, further studies have found patients can lose significant muscle mass during treatment. Quoted numbers range between 10 and 25 percent muscle loss (10, 11). In my practice, I have seen an average of 50 percent muscle loss. Because of this tendency, those taking tirzepatide and semaglutide need to make lifestyle changes to offset this, including weight training and diet.

We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications is becoming clearer. Emphasizing a plant-based diet focused on whole fruits, vegetables, beans and legumes can improve your outcomes. 

If you choose a medical approach, you still need to make significant lifestyle changes to overcome its risks.

References: 

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Thyroid. 2006 Mar;16(3):249-58. (9) N Engl J Med 2022;387:205-216. (10) AACE Clin Case Reports. 2025 Mar-Apr.;11(2):98-101. (11) Diabetes, Obesity and Metabolism. 2025 May. 27(5): 2720-2729.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

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Kidney health. METRO photo
Regular screening for CKD can help identify early stage kidney disease

By David Dunaief, M.D.

Dr. David Dunaief

In last week’s article about chronic kidney disease (CKD), we learned that roughly 90 percent of U.S. adults who have CKD are not even aware they have it (1). How can this be?

CKD can be asymptomatic in its early stages. Once it reaches moderate stages, vague symptoms like fatigue, malaise and loss of appetite typically surface. When CKD reaches advanced stages, symptoms become more obvious and troublesome.

Your kidneys are basically blood filters. They remove waste, toxins, and excess fluid from your body. They also play roles in controlling your blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in your blood.

When your kidneys aren’t operating at full capacity, you can experience heart disease, stroke, anemia, infection, and depression – among others.

When should you be screened for CKD?

Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease.

If you have diabetes, you should have your kidney function checked annually (2). If you have other risk factors, like high blood pressure, heart disease, or a family history of kidney failure, talk to your physician about establishing a regular screening schedule.

A 2023 study by Stanford School of Medicine recommends screening all U.S. adults over age 35. The authors conclude that the costs for screening and early treatment are lower than the long-term cost of treatment for those who are undiagnosed until they have advanced CKD (3). They also project that early screening and treatment will improve life expectancy.

How can you protect your kidneys?

Walking regularly and reducing protein and sodium consumption can help. One study shows that walking reduces the risk of death by 33 percent and the need for dialysis by 21 percent (4). Those who walked more often saw better results: participants who walked one or two times a week had a 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. The study included 6,363 participants with an average age of 70 who were followed for an average of 1.3 years.

With CKD, more dietary protein may be harmful. In a meta-analysis of 17 studies of non-diabetic CKD patients who were not on dialysis, results showed that the risk of progression to end-stage kidney disease, including the need for dialysis or a kidney transplant, was reduced 36 percent in those who consumed a very low-protein diet, rather than a low-protein or a normal protein diet (5).

How much sodium is too much? Results of one study showed that modest sodium reduction in our diet may be sufficient to help prevent proteinuria (protein in the urine) (6). Here, less than 2000 mg per day was shown to be beneficial.

What role do high blood pressure medications play?

Certain medications, ACE inhibitors or ARBs, are regularly prescribed to patients who have diabetes to protect their kidneys. ACEs and ARBs are two classes of high blood pressure medications that work on the kidney systems responsible for blood pressure and water balance (7). 

What about patients who do not have diabetes? Study results show that these medications reduced the risk of death significantly in patients with moderate CKD. Most of the patients were considered hypertensive. However, there was a high discontinuation rate among those taking the medications. If you exclude discontinuations, the results are robust with a 63 percent reduction in mortality risk.

What about NSAIDs?

Non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen, have been associated with CKD progression and with kidney injury in those without CKD (1). NSAIDs can also interfere with the effectiveness of ACE inhibitors or ARBs. Talk to your doctor about your prescription NSAIDs and any other over-the-counter medications and supplements you are taking.

What should I focus on?

It’s critical to protect your kidneys. Fortunately, basic lifestyle modifications can help; lowering sodium modestly, lowering your protein consumption, and walking frequently may all be viable options. Talk to your physician about your medications and supplements and about whether you need regular screening. 

References:

(1) cdc.gov. (2) niddk.nih.gov (3) Annals of Int Med. 2023;176(6):online. (4) Clin J Am Soc Nephrol. 2014;9(7):1183-9. (5) Cochrane Database Syst Rev. 2020;(10):CD001892. (6) Curr Opin Nephrol Hypertens. 2014;23(6):533-540. (7) J Am Coll Cardiol. 2014;63(7):650-658.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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METRO photo

By David Dunaief M.D.

Dr. David Dunaief

Your kidneys do far more than filter waste and fluid from your body. They maintain your blood’s health, help control your blood pressure, make red blood cells and vitamin D, and control your body’s acid levels. With all these functions relying on them, it’s crucial to keep them operating well.

When kidney function degrades, you can experience hypertension or cardiovascular problems. In later stages of chronic kidney disease (CKD), you may require dialysis or a kidney transplant. For the best outcomes, it’s critical to identify CKD early and arrest its progression to more serious stages. However, of the estimated 35.5 million U.S. adults who have CKD, as many as 9 in 10 are not even aware they have it (1).

Unfortunately, early-stage CKD symptoms are not obvious and can be overlooked. Among them are foamy urine, urinating more or less frequently than usual, itchy or dry skin, fatigue, nausea, appetite loss, and unintended weight loss (2).

Fortunately, simple tests, such as a basic metabolic panel and a urinalysis, can confirm your kidney function. These indices include an estimated glomerular filtration rate (eGFR), creatinine level and protein in the urine. eGFR is a calculation and, while the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 is classified as having mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the severity of CKD increases.

What can be done to address early-stage CKD, before you experience complications? Several studies have evaluated different lifestyle modifications and their impacts on its prevention, treatment and reversal.

What creates the greatest kidney risks?

Among the greatest risks for your kidneys are uncontrolled diseases and medical disorders, such as diabetes and hypertension (1). If you have — or are at risk for — diabetes, control your blood sugar levels to limit kidney damage. Similarly, if you have hypertension, controlling it will put less stress on your kidneys. For these diseases, it’s important to have your kidney function tested at least once a year.

In addition, obesity and smoking are risk factors and can be managed by making lifestyle changes.

How can diet help protect your kidneys?

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (3).

What is the significance of metabolic acidosis? Body fluids become acidic, and it is associated with CKD. The authors concluded that both sodium bicarbonate and diets including fruits and vegetables helped protect the kidneys from further damage in patients with CKD. Alkali diets are primarily plant-based, although not necessarily vegetarian or vegan. Animal products tend to cause an acidic environment.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (4). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower eGFR levels.

The most interesting part with sodium was that the difference between higher mean consumption and a lower mean consumption was not large, 2.4 grams compared to 1.7 grams. In other words, a difference of approximately a quarter-teaspoon of sodium per day was responsible for decrease in kidney function.

The National Kidney Foundation recommends diets that are higher in fruit and vegetable content and lower in animal protein, including the Dietary Approaches to Stop Hypertension (DASH) diet and plant-based diets (2). 

In my practice, when CKD patients follow a vegetable-rich, nutrient-dense diet, they experience substantial kidney function improvements. For instance, one patient improved his baseline eGFR from 54 to 63 after one month of dietary changes, putting him in the range of “normal” kidney functioning. Note that this is one patient, not a rigorous study.

How often should you have your kidney function tested?

It is important to have your kidney function checked as part of your regular physical. If your levels are low, you should address the issue through medications and lifestyle modifications to manage and reverse early-stage CKD. If you have common risk factors, such as diabetes, smoking, obesity or high blood pressure, or if you are over 60 years old, talk to your doctor about regular testing. 

Don’t wait until symptoms and complications occur. In my experience, it is much easier to treat and reverse CKD in its earlier stages.

References:

(1) CDC.gov. (2) kidney.org. (3) Clin J Am Soc Nephrol. 2013;8:371-381. (4) Clin J Am Soc Nephrol. 2010; 5:836-843.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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METRO photo
Increasing potassium may improve health outcomes

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

How are sodium and potassium related?

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

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

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

Why lower your sodium consumption?

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

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

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

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

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

Isn’t too little sodium a risk?

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

Why focus on potassium consumption?

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

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

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

References:

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

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Reducing dairy consumption can decrease inflammation

By David Dunaief, M.D.

Dr. David Dunaief

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

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

The effect of losing weight on OA pain

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

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

Does vitamin D help ease OA pain?

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

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

What about dairy?

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

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

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

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

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

Is diet or exercise better for reducing osteoarthritis pain?

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

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

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

References:

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

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Lowering cortisol levels can help manage weight

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

Balancing protein, carbohydrates and fats

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

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

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

Should we avoid refined carbohydrates?

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

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

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

Focusing on micronutrients 

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

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

Cortisol levels and weight

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

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

References:

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

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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The microbiome affects our immune system responses

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

What affects our microbiome?

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

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

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

Does the microbiome affect weight?

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

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

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

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

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

Gut bacteria and autoimmune disease

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

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

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

References:

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

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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