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By David Dunaief, M.D.

Dr. David Dunaief

Heart disease gets a lot of attention, because it’s still the number one cause of death in the U.S. We know that diet plays a significant role in this, but so do our genes.

What if we could tackle genetic issues with diet? 

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

The role of genes

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It aligns with what we see in modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that this study does not support that. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, such as with a plant-rich diet, such as a Mediterranean-type diet.

Can we improve our genetic response with diet?

The New England Journal of Medicine published study about the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, the risk profile improvement occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence,” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two opposing opinions, split by field. You may be surprised by which group liked it and which did not.

Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

So, what have we learned? Even with a genetic proclivity toward cardiovascular disease, we can alter our cardiovascular destinies.

References: 

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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

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While they can be scary, most thyroid nodules are benign

By David Dunaief, M.D.

Dr. David Dunaief

Thyroid nodules are diagnosed, often incidentally, on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck, rather than because of symptoms (1). More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound (2). Fortunately, most are benign. A small percent are malignant. Depending on the study, this can range from 1.1 to 6.5 percent of nodules (3, 4). 

There is a conundrum of what to do with a thyroid nodule. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (5). While most are asymptomatic, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (6).

FNA biopsy is becoming more common. In a study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (7). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam (8).

Evaluating indeterminate FNA results

As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two techniques to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test.

A meta-analysis of six studies of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies, but it did not do a good job of identifying those who did have cancer (9).

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (10).

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid.

Significance of calcification

Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (11). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk.

Considering a “wait and follow-up” approach

As I mentioned above, most thyroid nodules are benign. The results of one study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (12). The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that, after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

Thyroid function’s role

In considering risk factors, it’s important to note that those who had normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (13).

Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. Why the mortality rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially of the two most common forms, follicular and papillary.

References: 

(1) uptodate.com. (2) AACE 2013 Abstract 1048. (3) Thyroid. 2005;15(7):708. (4) European Thyroid Journal. 2022 Jun 29;11(4) online. (5) AACE 2013 Abstract 1048. (6) thyroid.org. (7) AAES 2013 Annual Meeting. Abstract 36. (8) AACE 2013 Abstract 1048. (9) Cancer. 2011;117(20):4582-4594. (10) J Clin Endocrinol Metab. Online May 12, 2015. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) J Clin Endocrinol Metab. 2006;91(11):4295.

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

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Mild headaches and fatigue are common consequences

By David Dunaief, M.D.

Dr. David Dunaief

During the summer, we talk a lot about the dangers of dehydration. However, it can also cause problems during the cooler winter months. Dry heat quickly evaporates moisture in the air, making it hard to stay hydrated or to keep any humidity in your home or office. This can dehydrate us.

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

In addition, the dry air can make our throats and sinuses dry, making us uncomfortable and more susceptible to irritations and viruses.

Let’s look at some of the consequences of dehydration and suggestions for keeping hydration up.

Headaches and migraines

In a review of studies published in the Handbook of Clinical Neurology, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (1). Headache intensity decreased as well.

Heart palpitations

Heart palpitations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise contributing to this (2). They occur mainly when we don’t hydrate prior to exercise. If you drink one glass of water before exercise and then drink during exercise, it will help avoid palpitations. Though these symptoms are not usually life-threatening, they can make you anxious.

Heart attacks

The Adventist Health Study showed that men who drank more water had the least risk of death from heart disease (3). Group one, which drank more than five glasses of water daily, had less risk than group two, which drank more than three. Those in group three, which drank fewer than two glasses per day, saw the lowest benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

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

Decreased concentration and fatigue

Mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women in a small study (4). The mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

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

How much water?

How do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data, but did not find adequate studies to suggest that eight glasses is the magic number (5). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like Mediterranean or Dietary Approaches to Stop Hypertension (DASH) diets, have a plant-rich focus. Diets with a focus on fruits and vegetables increase water consumption (6). As you may know, 95 percent of the weights of many fruits and vegetables are attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Remember that salty foods can dehydrate you, including breads and pastries, so try to avoid these.

Caffeinated beverages

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (7). With moderate amounts of caffeinated beverages, the liquid has a more hydrating effect than its diuretic effect.

Keeping some humidity in the air

To reduce sinus inflammation and dry skin that heated air can promote, measure the humidity level in your home with a hygrometer and target keeping it between 30 and 50 percent (8). When the temperature outside drops below 10 degrees F, lower this to 25 percent.

Strategies for adding moisture to the air include using cool mist humidifiers, keeping the bathroom door open after you bathe or shower, and placing bowls of water strategically around your home, including on your stovetop when you cook. If you use a humidifier, take care to follow the manufacturer’s care instructions and clean it regularly.

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

References: 

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

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

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It’s time to change up your holiday dinner options

By David Dunaief, M.D.

Dr. David Dunaief

Many consider Thanksgiving a time to indulge and not think about the repercussions. Even if we have the best of intentions, it’s hard to resist indulging in our childhood favorites and secret family recipes spread before us in a sprawling buffet.

Unfortunately, that one meal, and perhaps subsequent leftover meals, can have striking health consequences. And if you tend to overeat, be aware that there are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when many gain the predominant amount of weight for the entire year. However, most do not lose the weight they gain during this time (1). If you can fend off weight gain during the holidays, think of the possibilities for the rest of the year.

If you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (2). 

The good news is that, with a little Thanksgiving planning, you can reap significant health benefits.

What can we do to turn Thanksgiving dinner into a healthy meal? The secret is likely there on your table, hidden in the side dishes. By reconsidering how we prepare them, we can change the Thanksgiving health equation.

Refocus on plants

Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. Carotenoids make up a family of more than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (3).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer, amyotrophic lateral sclerosis (Lou Gehrig’s disease), age-related macular degeneration, and cardiovascular disease — heart disease and stroke. Foods that contain these substances are dark green leafy vegetables, as well as orange, yellow and red vegetables and fruits.

Focus on healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are obstacles to healthy eating. Two critical factors are presentation and perception.

Vegetables are often prepared in either an unappetizing way — steamed to the point of no return — or smothered in cheese and butter, negating their benefits, but clearing our consciences. Fruits are buttered and sugared beyond recognition or used as a garnish on more decadent dishes.

Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. 

Here are some suggestions to get you thinking about ways to shift the heavy holiday meal paradigm:

Make healthy, plant-based dishes part of the main course. You don’t have to forgo signature dishes, but supplement tradition by adding mouthwatering vegetable-based dishes. One of my favorites is steamed “sweet” vegetables — cauliflower, broccoli, snap peas, onions and garlic. To make it sweet, I sauté it in a splash of citrus-infused balsamic vinegar and add sliced apples. If you want to make this a primary dish, add diced tofu and/or garbanzo beans to make it more filling without overwhelming its delicate sweetness.

Improve vegetable choices. Why would you serve vegetables without any seasoning? In my family, we season vegetables and make sauces to drizzle over them. Personally, I’m a fan of infused vinegars. Each adds a different flavor to the vegetables. 

My 16-year-old nephew, who has never liked cooked vegetables, fell in love with my wife’s roasted Brussels sprouts and broccoli while on vacation last summer. He actually texted her a week later to ask for the recipes. Now, he makes them for himself. Good resources for appealing dishes can be found at PCRM.org, mouthwateringvegan.com, and many other resources.

Replace refined grains. A study in the American Journal of Clinical Nutrition, showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (4). Not only did participants lose subcutaneous fat found just below the skin, but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer. 

For even better results, consider substituting riced cauliflower or mashed cauliflower for rice or potatoes. You can purchase frozen riced cauliflower in many grocery stores now. Just be sure to get one that’s unsalted. If you prefer mashed, I have a simple recipe for mashed cauliflower here: https://medicalcompassmd.com/post/mashed-cauliflower-recipe-vegan 

Create a healthy environment. Instead of putting out creamy dips, cheese platters and candies as snacks, choose whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.

Offer healthy dessert options. Options might include dairy-free pumpkin pudding and fruit salad. The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods. 

Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and that increase your risk for chronic diseases, promote everyone’s health, while maintaining the theme of a traditional festive meal.

References: 

(1) N Engl J Med 2000; 342:861-867. (2) www.heart.org. (3) Crit Rev Food Sci Nutr 2010;50(8):728–760. (4) Am J Clin Nutr 2010 Nov;92(5):1165-71.

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

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Exercise can actually reduce a cold’s duration

By David Dunaief, M.D,

Dr. David Dunaief

With autumn upon us, cold season is sneaking up on us. Most frequently caused by the notorious human rhinovirus, a cold’s effects can range from an annoyance to more serious symptoms that put us out of commission for a week or more.

The good news is that it may be possible to reduce the symptoms — or even reduce the duration — of a common cold with supplements and lifestyle management.

Here, we’ll separate myth from fact about which supplements may be beneficial and which may not. 

How can you get symptom relief?

Let’s start with the basics to meet your most immediate need when you start experiencing cold symptoms.

If you have congestion or coughing symptoms, time-tested symptom relief may help. Sitting in a steamy bathroom, which simulates a medical mist tent, can help. Remember, dry heat is your enemy. If your home is dry, use a cool mist humidifier to put some humidity back in the air.

Consuming salt-free soups loaded with vegetables can help increase your nutrient intake and loosen congestion. I start with a sodium-free base and add in spices, onions, spinach, broccoli, and other greens until it’s more stew-like than soup-like. Caffeine-free hot teas will also help loosen congestion and keep you hydrated.

Does zinc really help?

You may have heard that zinc helps treat a cold. But what does the medical literature say? The answer is a resounding, YES!

According to a meta-analysis that included 13 trials, zinc in any form taken within 24 hours of first symptoms may reduce the duration of a cold by at least one day (1). Even more importantly, zinc may significantly reduce the severity of your symptoms throughout, improving your quality of life. This may be due to an anti-inflammatory effect.

One of the studies, which was published in the Journal of Infectious Disease, found that zinc reduced the duration of the common cold by almost 50 percent from seven days to four days, cough symptoms were reduced by greater than 60 percent and nasal discharge by 33 percent (2). Researchers used 13 grams of zinc acetate per lozenge taken three-to-four times daily for four days. This translates into 50-65 mg per day.

There are a few serious concerns with zinc. First, the dose researchers used was well above the maximum intake recommended by the National Institutes of Health, which is 40 mg per day for adults. This maximum intake number is less for those 18 and younger (3). Also, note that the FDA has warned against nasal zinc administration with sprays, which has led to permanent loss of smell for some people.

As for the studies, not all studies showed a benefit. Also, studies where there was a proven benefit may have used different formulations, delivery systems and dosages, and there is no current recommendation or consensus on what is optimal.

What about vitamin C?

According to a review of 29 trials with a combined population of over 11,000, vitamin C did not show any significant benefit in prevention or reduction of cold symptoms or duration in the general population (4). Thus, there may be no reason to take mega-doses of vitamin C for cold prevention and treatment. However, in a sub-group of serious marathon runners and other athletes, there was substantial risk reduction when taking vitamin C prophylactically; they caught 50 percent fewer colds.

Is echinacea a magic bullet?

After review of 24 controlled clinical trials, according to the Cochrane Database, the jury is still out on the effectiveness of echinacea for treatment of duration and symptoms, but the results are disappointing presently and, at best, are inconsistent (5). There are no valid randomized clinical trials showing cold prevention using echinacea.

In a randomized controlled trial with 719 patients, echinacea was no better than placebo for the treatment of the common cold (6).

Should you exercise?

People with colds need rest — at least that was the theory. However, a study published in the British Journal of Sports Medicine may have changed this perception. Participants who did aerobic exercise at least five days per week, versus one or fewer days per week, had a 43 percent reduction in the number of days with colds over two 12-week periods during the fall and winter months (7). Even more interesting is that those who perceived themselves to be highly fit had a 46 percent reduction in the number of days with colds compared to those who perceived themselves to have low fitness. The symptoms of colds were reduced significantly as well.

What’s the upshot?

For symptom relief, simple home remedies may work better than any supplements. Zinc is potentially useful in treating and preventing the common cold. Use caution with dosing, however, to reduce side effects. Echinacea and vitamin C may or may not provide benefits, but don’t stop taking them if you feel they help you. Lastly, exercise can actually reduce your cold’s duration.

References: 

(1) Open Respir Med J. 2011; 5: 51–58. (2) J Infect Dis. 2008 Mar 15;197(6):795-802. (3) ods.od.nih.gov. (4) Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. (5) Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000530. (6) Ann Intern Med. 2010;153(12):769-777. (7) British Journal of Sports Medicine 2011;45:987-992.

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

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New research on PSA outcomes can inform your screening decisions

By David Dunaief, M.D.

Dr. David Dunaief

You may see more fuzzy faces among men this month. Welcome to “Movember,” when men grow facial hair to raise awareness and research money for men’s health issues (1). An initiative of the Movember Foundation, the intention is to fund men’s health projects focused on mental health and suicide prevention, prostate cancer, and testicular cancer.

Its prostate cancer initiatives focus on early detection, treatment options, and quality of life considerations for different treatments. Here, I’ll add prevention options to the conversation.

Regardless of your family history, you can reduce your risk of prostate cancer with simple lifestyle modifications. Factors that contribute to increased risk include obesity, animal fat, and supplements. Equally as important, factors that reduce risk include vegetables, especially cruciferous vegetables, and tomato sauce or cooked tomatoes.

I’ll also share new research to inform your decision-making about prostate-specific antigen (PSA) screening.

Obesity’s effect

According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer; however, it may also increase your risk of aggressive disease (2). Because larger prostates make biopsies less effective, the authors attribute the lower incidence of nonaggressive cancer to the possibility that it is more difficult to detect it in obese men. Ultimately, those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Animal fat

There appears to be a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, those who consumed the highest amount of animal fat had a 63 percent increased risk of in advanced or metastatic prostate cancer, compared to those who consumed the least (3).

Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you continue to eat red meat, reduce your frequency as much as possible, targeting once a month or quarter.

In another large, prospective observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (4).

Cooked tomatoes

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown the same beneficial effects. It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit. Tomatoes need to be cooked to release lycopene (5). 

As part of this larger study, 32 patients with localized prostate cancer consumed 30 mg of lycopene per day via tomato sauce-based dishes over a three-week period before radical prostatectomy. Key cancer indicators improved, and tissue tested before and after the intervention showed dramatic improvements in DNA damage in leukocyte and prostate tissue (6). 

In a prospective study involving 47,365 men who were followed for 12 years, prostate cancer risk was reduced by 16 percent with higher lycopene intake from a variety of sources (7). When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

Although tomato sauce may be beneficial, many brands are loaded with salt, which creates its own bevy of health risks. I recommend to patients that they either make their own sauce or purchase prepared sauce made without salt.

Cruciferous vegetables

While results among studies vary, they all agree: consumption of vegetables, especially cruciferous vegetables, help reduce prostate cancer risk.

In a case-control study, participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (8). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

A separate study of 1338 patients with prostate cancer in a larger cancer screening trial concluded that, while vegetable and fruit consumption did not appear to lower outright prostate cancer risk, increased consumption of cruciferous vegetables — specifically broccoli and cauliflower — did reduce the risk of aggressive prostate cancer, particularly of more serious stage 3 and 4 tumors (9). These results were seen with consumption of just one or more servings of each per week, when compared to less than one per month.

What about PSA screening?

In a recently published retrospective analysis of 128 Veteran’s Administration facilities, those where PSA screening was less frequent found higher rates of metastatic prostate cancer (10). During the study period from 2005 to 2019, researchers found an inverse relationship between PSA screening rates and metastatic prostate cancer. When screening rates decreased, rates of metastatic cancer increased five years later, while in facilities where screening rates increased, metastatic cancer rates decreased. While the study authors caution about extending these findings to the general population, they do suggest they could help inform conversations between men and their physicians about the value of PSA screening. 

When it comes to preventing prostate cancer and improving prostate cancer outcomes, lifestyle modifications, including making dietary changes, can reduce your risk significantly.

References: 

(1) www.movember.com. (2) Epidemiol Rev. 2007;29:88. (3) J Natl Cancer Inst. 1993;85(19):1571. (4) Am J Epidemiol. 2009;170(9):1165. (5) Exp Biol Med (Maywood). 2002; 227:914-919. (6) J Natl Cancer Inst. 2002;94(5):391. (7) Exp Biol Med (Maywood). 2002 Nov;227(10):886-93. (8) J Natl Cancer Inst. 2000;92(1):61. (9) J Natl Cancer Inst. 2007;99(15):1200-1209. (10) JAMA Oncol. Published online October 24, 2022.

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

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Legume consumption plays an important role

By David Dunaief, M.D.

Dr. David Dunaief

Coronary artery disease is the most common type of heart disease, which can cause heart attacks. How common is it? According to the Centers for Disease Control and Prevention, about 6.7 percent of U.S. adults over the age of 19 have coronary artery disease (CAD) (1). There are 805,000 heart attacks in the U.S. annually, and 200,000 of these occur in those who’ve already had a first heart attack.

Among the biggest contributors to heart disease risk are high blood pressure, high cholesterol, and smoking. In addition, if you have diabetes or are overweight or obese, your risk increases significantly. Lifestyle factors also contribute to your risk: poor diet, lack of physical activity and high alcohol consumption are among the most significant contributors.

This is where we can have a tremendous impact and significantly reduce the occurrence of CAD. Evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Changes that garner a big bang for your buck include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Chocolate’s benefits

Preliminary evidence shows that two pieces of chocolate a week may decrease the risk of a heart attack by 37 percent, compared to those who consume less (2). However, the authors warned against the idea that more is better. In fact, high fat and sugar content and calorically dense aspects may have detrimental effects when consumed at much higher levels. There is a fine line between potential benefit and harm. The benefits may be attributed to micronutrients referred to as flavonols.

I usually recommend that patients have one to two squares — about one-fifth to two-fifths of an ounce — of high-cocoa-content dark chocolate daily. Aim for chocolate labeled with 80 percent cocoa content.

Alternatively, you can get the benefits without the fat and sugar by adding unsweetened, non-Dutched cocoa powder to a fruit and vegetable smoothie.

Who says prevention has to be painful?

Increase dietary fiber

Fiber has a dose-response relationship to reducing risk. In other words, the more fiber you eat, the greater your risk reduction. In a meta-analysis of 10 studies, results showed for every 10-gram increase in fiber, there was a corresponding 14 percent reduction in the risk of a cardiovascular event and a 27 percent reduction in the risk of heart disease mortality (3). The authors analyzed data that included over 90,000 men and 200,000 women.

According to a 2021 analysis of National Health and Nutrition Examination Survey (NHANES) data from 2013 to 2018, only 5 percent of men and 9 percent of women get the recommended daily amount of fiber (4).

The average American consumes about 16 grams per day of fiber (5).

So, how much is “enough”? The Academy of Nutrition and Dietetics recommends 14 grams of fiber for each 1,000 calories consumed, or roughly 25 grams for women and 38 grams for men (6).

We can significantly reduce our risk of heart disease if we increase our consumption of fiber to reach the recommended levels. Good sources of fiber are fruits and vegetables with the edible skin or peel, beans and lentils, and whole grains.

Consume more legumes

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, legumes reduced the risk of coronary heart disease by a significant 22 percent (7). Those who consumed four or more servings per week saw this effect when compared to those who consumed less than one serving per week. The legumes used in this study included beans, peas and peanuts. There were over 9,500 men and women involved, and the study spanned 19 years of follow-up.

I recommend that patients consume at least one to two servings a day, or 7 to 14 a week. Imagine the impact that could have, compared to the modest four servings per week used to reach statistical significance in this study.

Focus on healthy nuts

In a study with over 45,000 men, there were significant reductions in CAD with omega-3 polyunsaturated fatty acids (PUFAs). Both plant-based and seafood-based omega-3s showed these effects (8). Good sources of omega-3s from plant-based sources include nuts, such as walnuts, and ground flaxseed.

Your ultimate goal should be to become “heart attack proof,” a term used by Dr. Sanjay Gupta and reinforced by Dr. Dean Ornish. While even modest dietary changes can significantly reduce your risk, the more significant the lifestyle changes you make, the closer you will come to achieving this goal.

References: 

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) nutrition.org (5) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (6) eatright.org. (7) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (8) Circulation. 2005 Jan 18;111(2):157-164.

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

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Sugar control and regular eye exams are your best defense

By David Dunaief, M.D.

Dr. David Dunaief

We talk a lot in the medical community about the vascular consequences of diabetes, and rightly so. If you have diabetes, you are at high risk of vascular complications that can be life-altering. Among these are macrovascular complications, like coronary artery disease and stroke, and microvascular effects, such as diabetic nephropathy and retinopathy.

Here, we will discuss diabetic retinopathy (DR), the number one cause of blindness among U.S. adults, ages 20 to 74 years old (1). Diabetic retinopathy (DR) is when the blood vessels that feed the light-sensitive tissue at the back of your eye are damaged, and it can progress to blurred vision and blindness.

As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (2). Why does this matter? Because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.

Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by fluid accumulating in the macula (3). An oval spot in the central portion of the retina, the macula is sensitive to light. When fluid builds up from leaking blood vessels, it can cause vision loss.

Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (2).

In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (4). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

Unfortunately, the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse the damage.

Treatment options

While DME has traditionally been treated with lasers, injections of anti-VEGF medications may be more effective. These eye injections work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (5).

The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were equally effective in treating DME (6). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).

Risk from diabetes treatments

You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (7). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings for other significant issues.

To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.

This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (8). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both studies had weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (9). There are additional studies underway to clarify these results.

Glucose control and diet

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (10). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, an inference can be made: a nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (11, 12).

If you have diabetes, the best way to avoid diabetic retinopathy and DME is to maintain good control of your sugars. Also, it is imperative that you have a yearly eye exam by an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.

References: 

(1) cdc.gov. (2) www.aao.org/ppp. (3) www.uptodate.com. (4) JAMA Ophthalmol. 2014;132:168-173. (5) Community Eye Health. 2014; 27(87): 44–46. (6) ASRS. Presented 2014 Aug. 11. (7) Arch Intern Med. 2012;172:1005-1011. (8) Arch Ophthalmol. 2010 March;128:312-318. (9) Arch Intern Med. 2012;172:1011-1013. (10) www.nei.nih.gov. (11) OJPM. 2012;2:364-371. (12) Am J Clin Nutr. 2009;89:1588S-1596S.

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

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Cut down on late night snacking to avoid GERD. METRO photo
Increased fiber and exercise improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

After a large meal, many people suffer from occasional heartburn and regurgitation, where stomach contents flow backward up the esophagus. This reflux happens when the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Many incidences of reflux are physiologic (normal functioning), especially after a meal, and doesn’t require medical treatment (1).

Gastroesophageal reflux disease (GERD), on the other hand, is long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). This is one reason pharmaceutical firms give it so much attention, lining our drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers can also play a role. They can include spicy, salty, or fried foods, peppermint, and chocolate.

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Let’s examine available treatments and ways to reduce your risk.

Evaluate medication options

The most common and effective medications for treating GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use include increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Understand PPI risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (9). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician. Before stopping PPIs, consult your physician. Rebound hyperacidity (high acid produced) can result from stopping them abruptly.

Increase fiber and exercise

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the study that quantified the risks of smoking and salt, fiber and exercise both had the opposite effect, reducing GERD risk (5). An analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (11).

Manage weight

In one study that examined obesity’s role in GERD exacerbation, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index.

Avoid late night eating

One of the most powerful modifications we can make to avoid GERD is among the simplest. A study showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.” While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References: 

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar; 130:639-649. (13) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

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

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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 cancer.org.

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.

References: 

(1) breastcancer.org. (2) uspreventiveservicestaskforce.org. (3) acog.org. (4) cancer.org. (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 www.medicalcompassmd.com.

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