Medical Compass

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Diet may have a significant impact on heart failure risk and outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Unlike a heart attack, which is acute, heart failure develops slowly and may take years to become symptomatic. Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. According to the American Heart Association, over six million Americans are affected, and the numbers are projected to increase significantly by 2030 (1).

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

Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue. Each of these can impact quality of life significantly.

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

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

Can diet improve heart failure?

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

In a population-based, prospective study, the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (2). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

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

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

More recently, the REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. 

The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (3). Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF.

Does iron supplementation improve heart failure outcomes?

An observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (4).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L.

The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients. However, studies of oral iron supplementation has not been shown to improve results, while intravenous supplementation has been shown to reduce hospitalizations and mortality (5).

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


(1) Circulation. 2020;141:e139–e596. (2) Am J Med. 2013 Jun:126(6):494-500. (3) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045. (4) Am Heart J. 2013;165(4):575-582. (5) Eur J Heart Fail. 2018;20(1):125–133.

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 or consult your personal physician.

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Flu, RSV and COVID-19 are especially tough on those with impaired lung function

By David Dunaief, M.D.

Dr. David Dunaief

Our experiences over the past several years with COVID-19 have increased our awareness of how chronic ailments can make us more vulnerable to the consequences of acute diseases circulating in our communities.

For those with chronic obstructive lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma, as well as those who smoke and vape, the consequences of the flu, RSV and COVID-19 are especially severe.

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

Do antioxidants improve asthma?

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

The good news is that there was only a small difference in behavior between the high- and low-antioxidant groups. The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Using carotenoid supplementation in place of antioxidant foods did not affect inflammation. The authors concluded that an increase in carotenoids from diet has a clinically significant impact on asthma in a very short period.

Can increasing fiber lower COPD risk?

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers.

In one study of men, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (3). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain, essentially a whole foods plant-based diet. The “high-fiber” group was still below the American Dietetic Association’s recommended intake of 14 grams per 1,000 calories each day.

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

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

What devices can help improve lung function?

An incentive spirometer is a device that helps expand the lungs when you inhale through a tube and cause a ball (or multiple balls) to rise in a tube. This inhalation opens the alveoli and may help you breathe better.

Incentive spirometry has been used for patients with pneumonia, those who have had chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (5). A small study showed that those who trained with an incentive spirometer for two weeks increased their lung function and respiratory motion. Participants were 10 non-smoking healthy adults who were instructed to take five sets of five deep breaths twice a day, totaling 50 deep breaths per day. Incentive spirometers are inexpensive and easily accessible.

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

How does exercise help improve lung function?

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

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

We all should be working to strengthen our lungs. This three-pronged approach of lifestyle modifications — diet, exercise and incentive spirometer — can help.


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

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

Getting a good night's rest helps keep your mind and body healthy. METRO image
Sleep apnea may increase your risks of cardiovascular disease and cancer

By David Dunaief, M.D.

Dr. David Dunaief

Our physical and mental wellbeing depends on getting quality, restful sleep; however, many of us struggle to achieve this. For those with obstructive sleep apnea (OSA), quality sleep is particularly elusive.

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

OSA diagnoses are classified as either mild, moderate or severe. It’s estimated that roughly 80 percent of moderate and severe OSA sufferers are undiagnosed.

After family history, most risk factors for OSA are modifiable. They include chronic nasal congestion, excess weight or obesity, alcohol use and smoking (2).

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

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

How does sleep apnea affect cardiovascular disease risk?

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

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

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

Does OSA increase your risk of cancer?

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

Does OSA affect male sexual function?

Erectile dysfunction (ED) may also be associated with OSA and, like other outcomes, CPAP may decrease this incidence. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspects of this study were that, at baseline, the participants were overweight, not obese, on average and were only 45 years old. 

In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

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

Can diet help address OSA?

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

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

If you think you are suffering from sleep apnea, you should be evaluated at a sleep lab and then follow up with your doctor. Don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are many effective treatments.


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

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

Processed meats increase risks of cancers, stroke and diabetes. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Many of us are starting to plan for Labor Day weekend, whether this means preparing for cookouts or getting ready for the new school year. It’s a good time to provide some food for thought — pun intended. 

The barbecues associated with this weekend usually include hot dogs, hamburgers, sausages, bacon, poultry and fish. Sounds mouthwatering, doesn’t it? Unfortunately, there are more and more studies that implicate processed meats as a potential cause of diseases, including several cancers, heart disease, stroke and diabetes.

Processed meats are those that have been cured, salted, fermented or smoked. A short list of processed meats includes hot dogs, ham, pepperoni, bacon, sausages and deli meats, among others. While these are barbecue and picnic favorites, more importantly, deli meats are often used as sandwich staples for adults’ and school children’s lunches. Turkey and roast beef were typically in my lunch box when I was growing up. The prevailing thought at the time was that deli meats that were made without nitrates, nitrites and preservatives were healthy. Unfortunately, more recent studies show otherwise.

Does processed meat increase stroke risk?

In a large, prospective cohort study published in the American Journal of Clinical Nutrition in 2011, results showed a 23 percent increased risk of stroke in men who consumed the most processed meats. Deli meats, including low-fat turkey, ham and bologna, considered healthy by some, were implicated. The 40,291 Swedish participants were followed for about ten years.

The increased risk could be attributed potentially to higher sodium content in processed meats. Another mechanism could be nitrates and nitrites. Interestingly, participants were mostly healthy, except for the processed meats. Thus, processed meats could interfere with the benefits of a heart-healthy diet, according to the authors.

How do processed meats affect cancer risk?

Physicians Committee for Responsible Medicine has been aggressive about communicating the connection between processed meats and cancer. They’ve run television ads, including ones encouraging us to “break up with bacon,” and a billboard portraying a cigarette pack with hot dogs, not cigarettes, sticking out the top. The message read, “Warning: Hot dogs can wreck your health.”

Let’s look at some of the studies that have prompted these warnings.

In the large prospective Multiethnic Cohort Study, there was a 68 percent increased risk of pancreatic cancer in participants who ate the highest amounts of processed meats compared to the lowest (1). Participants were followed for seven years. The authors believe that carcinogenic substances in meat preparation, not necessarily fat or saturated fat, were probably the reason for increased risk. Pancreatic cancer is deadly, since most patients don’t have symptoms; therefore, it’s not discovered until its very late stages. It has destroyed the lives of some extremely physically fit people, like Patrick Swayze who died at the age of 57.

Processed meats also increase the risk of colorectal cancer. In a meta-analysis, there was an increased risk of 14 percent per every 100 grams, or 3.5 ounces (approximately one serving) of processed meat per day (2). Two slices of deli meat are equal to one serving. A deli’s turkey sandwich includes about five servings of processed meat in one meal. 

In the EPIC trial, a prospective study with more than 420,000 participants, processed meats increased the risk of colorectal cancer by 35 percent (3). The absolute risk of developing colorectal cancer was 71 percent over ten years for those who were age 50. Interestingly, fish actually decreased the risk by 31 percent, making fish a better choice for the barbeque.

Other cancers implicated in processed meats include lung, liver and esophageal cancers, with increased risks ranging from 20-60 percent according to the NIH AARP Diet and Health study (4). A separate analysis of the EPIC trial showed that there was a greater than two times increased risk of esophageal cancer with processed meats (5).

Is there an association between type 2 Diabetes and processed meats?

In one of the most prestigious and largest meta-analyses involving the Health Professionals’ Follow-up Study and the Nurses’ Health Study I and II, results demonstrated a 32 percent increased risk of type 2 diabetes in participants who had a one-serving increase of processed meat consumption per day. 

This data was highly statistically significant and involved over four million years of cumulative follow-up. Interestingly, the authors estimate that replacing processed meat with one serving of nuts, low-fat dairy and whole grains would reduce risk substantially (6).

I believe warning labels should come with processed meats; however, this is unlikely to happen. Therefore, you need to be your own best advocate and read ingredients. It is not just processed meats on the barbecue this Labor Day weekend that are concerning, but the long-term effects of eating deli meats that are even more worrisome.


(1) J Natl Cancer Inst 2005;97 (19): 1458-1465. (2) PLoS One. 2011;6 (6):e20456. (3) J Natl Cancer Inst. 2005 Jun 15;97 (12):906-16. (4) PLoS Med. 2007 Dec;4 (12):e325. (5) J Natl Cancer Inst. 2006 Mar 1;98 (5):345-54. (6) Am J Clinical Nutrition 2011;94 (4): 1088-1096.

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 or consult your personal physician.

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Fiber plays an important role in immune system function

By David Dunaief, M.D.

Dr. David Dunaief

Autoimmune disease is an umbrella term that covers more than 80 different diseases (1). Among them are type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, multiple sclerosis, and inflammatory bowel disease. The common thread for all of them is that the body’s immune system is attacking organs, tissues and cells and causing chronic inflammation.

Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others.

Typical medical protocols

Immunosuppressives are the “go-to” treatment for autoimmune issues. In RA, for example, a typical drug regimen includes TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab), and methotrexate. These therapies reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

There are several concerning factors with these treatments.

First, the side-effect profiles are substantial. They include risks for cancers, opportunistic infections and even death (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

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

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

So, what other methods are available to treat autoimmune diseases? 

Medical nutrition therapy

Medical nutrition therapy using bioactive compounds and supplementation are being studied. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

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

What are the effects of fish oil?

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

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

Can probiotics help?

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

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

Does fiber intake affect autoimmune disorders?

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

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

Can diet substitute for medication?

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Bioactive compounds found in high-nutrient foods and supplements can have a profound impact on your immune system’s regulation and may help reset the immune system. Even in severe cases, bioactive compounds in foods may work in tandem with medications to treat autoimmune diseases more effectively and help reduce dosing of some immunosuppressives, minimizing potential side-effects.

This is not hypothetical. I have seen these effects in my practice, where patients have been able to reduce — or even eliminate —immunosuppressives by altering their diets.


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

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

Studies suggest lifestyle approaches to improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

Irritable bowel syndrome (IBS) symptoms, such as abdominal pain, cramping, bloating, constipation and diarrhea, can directly affect your quality of life. If you are among the estimated 10 to 15 percent of the population that suffers from IBS symptoms, managing these symptoms can become all-consuming (1).

While diagnosing IBS is challenging, physicians use discrete criteria physicians to provide a diagnosis and eliminate more serious possibilities. The Rome IV criteria comprise an international effort to help diagnose and treat functional gastrointestinal disorders. Using these criteria, which include frequency of pain and discomfort over the past three months, alongside a physical exam helps provide a diagnosis.

Fortunately, there are several approaches to improving symptoms that require only modest lifestyle changes.

How is IBS affected by mental state?

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

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

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

Could gluten be a factor in IBS?

Gluten sensitivity may be an important factor for some IBS patients (3). In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo, 68 percent vs. 40 percent, respectively (4). These results were highly statistically significant, and the authors concluded that nonceliac gluten intolerance may exist. 

I suggest to my patients that they might want to start avoiding gluten and then add it back into their diets slowly to see the results.

Does fructose play a role in IBS?

Some IBS patients may suffer from fructose intolerance. In a study, IBS researchers used a breath test to examine this possibility (5). The results were dose-dependent, meaning the higher the dose of fructose, the greater the effect researchers saw. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.

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

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (6). Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.

Are lactose intolerance and IBS connected?

Another small study found that about one-quarter of patients with IBS also have lactose intolerance (7). 

Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptoms at both six weeks and five years when placed on a lactose-restricted diet.

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

Will probiotics help with IBS?

A study that analyzed 42 trials focused on treatment with probiotics shows there may be a benefit to probiotics, although the objectives, or endpoints, were different in each trial (8).

Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.

Is there a link between IBS and migraines?

A preliminary study has suggested there may be a link between IBS and migraine and tension-type headaches. The study of 320 participants, 107 with migraine, 107 with IBS, 53 with episodic tension-type headaches (ETTH), and 53 healthy individuals, identified significant occurrence crossover among those with migraine, IBS and ETTH. Researchers also found that these three groups had at least one gene that was distinct from healthy participants. Their hope is that this information will lead to more robust studies that could result in new treatment options (9).

All of these studies provide hope for IBS patients. These are treatment options that involve modest lifestyle changes. Since the causes can vary, a strong patient-doctor connection can help in selecting an approach that provides the greatest symptom reduction for each patient.


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

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 or consult your personal physician.

New research suggests inflammation is associated with early Parkinson's disease­. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Parkinson’s disease (PD) is the second most common neurodegenerative disorder in the U.S. after Alzheimer’s disease. Estimates put the number of people living with Parkinson’s disease at up to 1.2 million, with 90,000 new diagnoses each year (1).

Patients with PD suffer from a collection of symptoms caused by the breakdown of brain neurons. There’s a lot we still don’t know about the causes of PD; however, risk factors may include head trauma, genetics, exposure to toxins and heavy metals, and lifestyle issues, like lack of exercise.

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (2). Adding back dopamine has been the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also by modifying lifestyle, considering factors like iron, vitamin D, inflammation, and CoQ10. While the research is not conclusive, it is intriguing and gives us more options.

What impact does iron have on the brain?

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

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (3).

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

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

What is the role of inflammation in PD?

In a recent study, researchers tested 58 newly diagnosed PD participants’ blood and compared their results to 62 healthy control participants (4). Some of the PD arm participants had additional testing done, including cerebrospinal fluid samples and brain imaging. All these tests were looking for specific inflammatory markers.

Researchers found that those with PD had significantly higher brain inflammation levels than those without PD in specific regions. Their blood and cerebrospinal fluid also had high inflammatory markers. These measures correlated with worse visuospatial and cognitive scores.

While this study provides hints of possible treatments, we need additional studies to identify whether the inflammation is a cause or an effect of PD.

Regardless, adopting a low-inflammatory foods diet might help mitigate some symptoms of PD or slow its advancement.

Does CoQ10 help slow PD progression?

There is evidence that CoQ10 may be beneficial in PD at high doses.

In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to a placebo group (5). Other doses of 300 and 600 mg showed trends toward benefit, but were not significant. This was a 16-month trial in a small population of 80 patients. Unfortunately, results for other CoQ10 studies have been mixed.

In this study, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with PD.

Does Vitamin D make a difference?

Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In a prospective study of over 3000 patients, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (6). This is impressive, especially since the highest quartile patients had vitamin D levels that were what we qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less.

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

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

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

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


(1) (2) (3) Antioxid Redox Signal. 2014;10;21(2):195-210. (4) Movement Disorders. 2023;38;5:743-754. (5) Arch Neurol. 2002;59(10):1541-1550. (6) Arch Neurol. 2010;67(7):808-811. (7) Am J Clin Nutr. 2013;97(5):1004-1013. (8) Neurologica. 2019;140(4):274-280.

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

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We know better. So why can’t we do better?

By David Dunaief, M.D.

Dr. David Dunaief

We are continuously inundated with messages about the importance of including fruits and vegetables in our daily diets. In addition to fiber, they include critical nutrients and micronutrients that keep us healthy and reduce our risks of developing chronic diseases.

Despite this, according to a 2022 report by the Centers for Disease Control and Prevention (CDC), an average of 12.3 percent of U.S. adults met the daily requirements for fruit intake, and an even more abysmal 10 percent met vegetable intake recommendations (1). As you might expect, it follows that we are deficient in many key micronutrients (2).

Why do we care? Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients. 

Here’s a stunning statistic: more than 50 percent of American adults have a chronic disease, with 27 percent having more than one (3). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade and are currently at around 77 years old.

One indicator of nutrient intake that we can measure is carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. I measure these regularly, because they give me a sense of whether the patient might lack potentially disease-fighting nutrients. A high nutrient intake dietary approach can resolve the situation and increase both carotenoid and other critical nutrient levels.

Why focus on a high nutrient intake diet?

A high nutrient intake diet focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals — plant nutrients. Micronutrients are bioactive compounds found mostly in foods and in some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum of them is greater than their parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (4).

A 20 percent increase in diet scores, which indicated an improved quality of diet, was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent more than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large, prospective cohort study, where the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

How can diet improve your quality of life?

Quality of life is as important as longevity. Let’s examine some studies that consider the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (6). The authors attribute this effect, at least partially, to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. Each tablespoon of olive oil contains 120 calories, all of them fat. If you eat too much of even good fat, it can be counterproductive. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s.

In a case-control study that compared those with and without disease, high intake of antioxidants from food was associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), the leading cause of blindness in those 55 years or older (7). This was true even when participants had a genetic predisposition for the disease.

There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can improve our outcomes. With a focus on a high nutrient intake diet, we can improve life expectancy and, on an individual level, improve our quality of life.


(1) Morb Mortal Wkly Rep 2022;71:1–9. (2) (3) (4) N Engl J Med 2017; 377:143-153. (5) BMJ. 2009;338:b2337. (6) Neurology June 15, 2011. (7) Arch Ophthalmol. 2011;129(6):758-766.

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 or consult your personal physician.

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Lowering your sodium intake can help

By David Dunaief, M.D.

Dr. David Dunaief

Although it’s possible to have a kidney stone without symptoms, more often they present with the classic symptoms of blood in the urine and colicky pain. The pain can be intermittent or constant, and it can range from dull to extremely painful, described by some as being worse than giving birth, being shot or being burned. The pain can radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1).

Stones are usually diagnosed through the symptoms and either abdominal x-rays or non-contrast CT scans.

Unfortunately, the first line treatment for passing kidney stones — at least small ones — involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are smaller than four millimeters pass spontaneously. Stones closest to the opening of the urethra are more likely to pass through on their own (2).

Generally, if you’ve passed a kidney stone, you know it.

In the case of a stone too large to pass naturally, a urologist may use surgery, ultrasound, or a combination of methods to break it into smaller pieces, so you can pass it. Unfortunately, once a patient forms one stone, the possibility of having others increases significantly over time. The good news is that there are several lifestyle changes you can make to reduce your risk.

How much water do you need to drink?

First, it is very important to stay hydrated and drink plenty of fluids, especially if you have a history of stone formation (3). You don’t have to rely on drinking lots of water to accomplish this, though. Increasing your consumption of fruits and vegetables that are moisture-filled can help, as well.

Do supplements play a role in stone formation?

One of the simplest methods is to reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones. Calcium oxalate is the dominant one, occurring approximately 80 percent of the time (4). Calcium supplements, therefore, increase the risk of kidney stones.

When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (5). According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (6). It did not matter whether study participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, calcium from dietary sources actually has the opposite effect, decreasing risk. In the same study, those participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest group. Paradoxically, calcium intake shouldn’t be too low, either, since that also increases kidney stone risk. Changing your source of calcium is an important key to preventing kidney stones.

What role does sodium play in stone formation?

Again, in the Nurses’ Health Study, participants who consumed 4.5 grams of sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 grams per day (6). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Does protein play a role in stone formation?

Animal protein may play a role. In a five-year, randomized clinical trial, men who reduced their consumption of animal protein to approximately two ounces per day, as well as lowering their sodium, were 51 percent less likely to experience a kidney stone than those who consumed a low-calcium diet (7). These were men who had histories of stone formation.

The reason animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that animal protein’s higher sulfur content produces more acid. This acid is neutralized by release of calcium from the bone (8). That calcium can then promote kidney stones.

Does blood pressure impact kidney stones?

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (9). Amazingly, it did not matter whether or not the patients were treated for high blood pressure with medications; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not just the symptoms. The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more that you implement, the lower your likelihood of stones.


(1) emedicine January 1, 2008. (2) J Urol. 2006;175(2):575. (3) J Urol. 1996;155(3):839. (4) N Engl J Med. 2004;350(7):684. (5) Kidney Int 2003;63:1817–23. (6) Ann Intern Med. 1997;126(7):497-504. (7) N Engl J Med. 2002 Jan 10;346(2):77-84. (8) J Clin Endocrinol Metab. 1988;66(1):140. (9) BMJ. 1990;300(6734):1234.

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 or consult your personal physician.

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Increasing dietary fiber can make a big difference

By David Dunaief, M.D.

Dr. David Dunaief

We all have hemorrhoids. They’re vascular structures that help control our stool. When they become irritated and inflamed, we often say we “have hemorrhoids.” What we really mean is that our hemorrhoids are causing us pain.

Many of us have suffered at one time or another from hemorrhoid pain. They affect men and women equally, though women have a higher propensity during pregnancy and childbirth.

When our hemorrhoids are irritated, we may experience itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They often bleed, especially during a bowel movement, which can be scary. Fortunately, hemorrhoids are not a harbinger of more serious disease.

There are two types of hemorrhoids: external, occurring outside the anus; and internal, occurring within the rectum.

Treating external hemorrhoids

Fortunately, external hemorrhoids tend to be mild. Most of the time, we can treat them with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H. 

Another treatment option is a sitz bath.  All of these can help relieve the pain. Because we can treat them with over-the-counter solutions, external hemorrhoids generally do not require a doctor’s appointment.

For a more comprehensive solution, the most effective way to reduce this bleeding and pain is to increase your fiber intake with dietary changes and supplementation (1). 

Sometimes, however, there is thrombosis (clotting) of external hemorrhoids. In these cases, they may become more painful and require medical treatment.

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should consult your physician to confirm it is not due to a malignancy or other cause, such as inflammatory bowel disease.

Treating internal hemorrhoids

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since the hemorrhoids are usually above the point of sensation in the colon, called the dentate line. If there is pain and discomfort, it’s generally because the internal hemorrhoids have prolapsed, or fallen out of place, due to weakening of the muscles and ligaments in the colon. This allows them to fall below the dentate line.

The first step for treating internal hemorrhoids is the same as for external hemorrhoids: add fiber through diet and supplementation. Study after study shows significant benefit. For instance, in a meta-analysis by the Cochrane Systems Data Review 2005, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, daily incidence of bleeding decreased dramatically (3).

What are the treatments for persistent hemorrhoid pain?

There are several minimally invasive options to address persistent and painful hemorrhoids, including banding, sclerotherapy and coagulation. The most effective of these is banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where rubber bands are placed at the neck of each hemorrhoid to cut off the blood flow. To avoid complications from constipation, patients should also take fiber supplementation. Side-effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgery) would be the next option.

How do you prevent hemorrhoid problems?

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, which can increase the risk of inflammation. Though you may want private time to read, the bathroom is not the library. As soon as you have finished moving your bowels, it is important to get off the toilet.

Get plenty of fluids. This helps soften the stool and prevent constipation. Exercise also helps prevent constipation. You should not hold in a bowel movement; go when the urge is there, or the stool can become hard, resulting in straining, constipation, and more time on the toilet.

How do I get more fiber?

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining.

Americans, on average, consume 16g per day of fiber (5). The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 to 38 grams, depending on gender and age (6). I typically recommend at least 40 grams. My wife and I try to eat only foods that contain a significant amount of fiber, and we consume approximately 65 grams a day.

You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned – side-effects are potentially gas and bloating for the first week or two.

I generally recommend adjusting your diet before reverting to supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes all have significant amounts of fiber. Grains, beans and nuts have among the highest levels of fiber. For instance, one cup of black beans has 12g of fiber.


(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-6. (2) (3) Hepatogastroenterology 1996;43(12):1504-7. (4) Dis Colon Rectum 2004 Aug;47(8):1364-70. (5) (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85.

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 or consult your personal physician.