Medical Compass

Symptoms of diverticular disease include fever and abdominal pain. METRO photo
Physical activity and fiber make a difference

By David Dunaief, M.D.

Dr. David Dunaief

Diverticular disease, or diverticulosis, becomes more common as we age. In the U.S., more than 30 percent of those aged 50-59 are affected and, for those over 80, approximately 70 percent are affected (1).

The good news is that modest lifestyle changes can potentially prevent it. Here, I will explain simple ways to reduce your risk, while also debunking a pervasive myth — that fiber, or more specifically nuts and seeds, exacerbates the disease.

What causes diverticular disease? 

Diverticular disease is a weakening of the lumen, or wall of the colon, which results in the formation of pouches or out-pocketing referred to as diverticula. Pressure from constipation may be part of the cause. 

Its mildest form, diverticulosis may be asymptomatic. In other cases, symptoms may include fever and abdominal pain, predominantly in the left lower quadrant in Western countries, or the right lower quadrant in Asian countries. It may need to be treated with antibiotics.

Diverticulitis affects 10 to 25 percent of those with diverticulosis. Diverticulitis is inflammation and infection, which may lead to a perforation of the bowel wall. Emergency surgery may be required if a rupture occurs.

Unfortunately, the incidence of diverticulitis is growing. In 2010, about 200,000 were hospitalized for acute diverticulitis, and roughly 70,000 were hospitalized for diverticular bleeding (2). For those between 40 and 49 years old, the incidence of diverticulitis grew 132 percent between 1980 and 2007, the most recent data on this population (3).

How do you prevent diverticular disease and its complications? 

There are several modifiable risk factors, including diet composition and fiber intake, along with weight and physical activity.

In a study that examined lifestyle risk factors for diverticulitis incidences, adhering to a low-risk lifestyle reduced diverticulitis risk almost 75 percent among men (4). The authors defined a low-risk lifestyle as including fewer than four servings of red meat a week, at least 23 grams of fiber a day, two hours of vigorous weekly activity, a body mass index of 18.5–24.9 kg/m2, and no history of smoking. They estimated that a low-risk lifestyle could prevent 50 percent of diverticulitis cases.

How do we know fiber helps?

A prospective study published online in the British Medical Journal extolled the value of fiber in reducing the risk of diverticular disease (5). This study was part of the EPIC trial, which involved over 47,000 people living in Scotland and England. It showed a 31 percent reduction in risk in those who were vegetarian.

But more intriguing, participants who had the highest fiber intake saw a 41 percent reduction in diverticular disease. Those participants in the highest fiber group consumed more than 25.5 grams per day for women and more than 26.1 grams per day for men, whereas those in the lowest group consumed fewer than 14 grams per day. Though the difference in fiber between the two groups was small, the reduction in risk was substantial.

Another study, which analyzed data from the Million Women Study, a large-scale UK study of middle-aged women, confirmed the correlation between fiber intake and diverticular disease, and further analyzed the impact of different sources of fiber (6). The authors’ findings were that reduction in the risk of diverticular disease was greatest with high intake of cereal and fruit fiber.

Most Americans get about 16 grams of fiber per day. The Institute of Medicine (IOM) recommends daily fiber intake for those under age 50 of 25-26 grams for women and 38 grams for men (7). Interestingly, their recommendations are lower for those who are over 50.

What if you consumed at least 40 grams of fiber per day? This is what I recommend for my patients. Some foods that contain the most fiber include nuts, seeds, beans and legumes. In a 2009 study, those men who specifically consumed the most nuts and popcorn saw a protective effect from diverticulitis (8).

Does obesity have an effect?

In the large, prospective male Health Professionals Follow-up Study, body mass index played a significant role, as did waist circumference (9). Those who were obese (BMI >30 kg/m²) had a 78 percent increased risk of diverticulitis and a greater than threefold increased risk of a diverticular bleed compared to those who had a BMI in the normal range of <21 kg/m². For those whose waist circumference was in the highest group, they had a 56 percent increase risk of diverticulitis and a 96 percent increase risk of diverticular bleed. Thus, obesity puts patients at a much higher risk of diverticulosis complications.

Does physical activity make a difference?

Physical activity is critical for reducing diverticular disease risk, although the exact mechanism is not yet understood. Regardless, the results are impressive. In a large prospective study, those with the greatest amount of exercise were 37 percent less likely to have diverticular disease compared to those with the least amount (10). Jogging and running seemed to have the most benefit. When the authors combined exercise with fiber intake, there was a dramatic 256 percent reduction in diverticular disease risk.

If you are focused on preventing diverticular disease and its complications, lifestyle modifications may provide the greatest benefit.


(1) (2) Clin Gastroenterol Hepatol. 2016; 14(1): 96–103.e1. (3) Gastroenterology. 2019;156(5): 1282-1298. (4) Am J Gastroenterol. 2017; 112: 1868-1876. (5) BMJ. 2011; 343: d4131. (6) Gut. 2014 Sep; 63(9): 1450–1456. (7) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85. (8) AMA 2008; 300: 907-914. (9) Gastroenterology. 2009;136(1): 115. (10) Gut. 1995;36(2): 276.

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.

METRO photo
Increase fruits, vegetables and whole grains and eliminate processed meats

By David Dunaief, M.D.

Dr. David Dunaief

For many of us, Independence Day launches a long string of summer barbecues. What if you could use these to kick-start your path to better health?

In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are barbecue and picnic staples. But there are healthier alternatives. If we lean into alternatives, like those found in a Mediterranean-style diet, we can improve our health while enjoying mouth-watering dishes.

The Mediterranean-style diet includes green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of fish and olive oil. The options are far from tasteless.

At a memorable family barbecue, we had an array of succulent choices. These included a three-bean salad, mandarin orange salad with mixed greens and a light raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon fillets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable shish kebobs, and a large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence that explains why these foods help us.

Cancer prevention

A systematic review initially published in 2016 and updated in 2017 provides a comprehensive look at the results of studies focused on weighing the effects of adherence to a Mediterranean-type diet on cancer risk and progression (1, 2). When the authors pooled and analyzed cohort studies and randomized control trials, they found an inverse relationship between cancer mortality risk and high adherence to the diet. This means that the more compliant participants were, the lower their risk of cancer mortality.

When making the same comparison between high adherence and low adherence from studies of specific cancers, they identified risk reductions for colorectal (17 percent), prostate (four percent), gastric (27 percent), and liver cancers (42 percent) (1). Further study also found high adherence reduced the risks of breast, head and neck, gallbladder, and biliary tract cancer (2).

The authors note that, while it’s improbable that any single component of the diet resulted in these effects, they were able to demonstrate significant inverse correlations between specific food groups and overall cancer risk. For example, the higher the regular consumption of fruits, vegetables, and whole grains, the lower the risk. All three of these fit right in at an outdoor feast!

Looking more closely at specific cancers, another study found that increased consumption of fruits and vegetables may help prevent pancreatic cancer. This is critical, since by the time there are symptoms, often the cancer has spread to other organs (3). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and non-citrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (4). Interestingly, cooked vegetables, not just raw ones, had a substantial effect.

Diabetes treatment and prevention

Fish might play an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of fish and seafood intake had a substantial decrease in risk of type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood. Therefore, there is nothing wrong with some grilled fish on the “barbie” to help protect you from developing diabetes.

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial, mixed nuts led to a substantial reduction of hemoglobin A1C, a very important biomarker for sugar levels for the previous three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease.

The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke prevention

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial.

Though these are promising results, I caution you to use no more than one tablespoon of olive oil per day, since it’s calorically dense. 

It is not difficult to substitute the beneficial Mediterranean-style diet for processed meats, or at least add them to the selection. This plant-based diet can help you prevent many chronic diseases. So, this Independence Day and beyond, plan to include some delicious, healthy choices.


(1) Curr Nutr Rep. 2016; 5: 9–17. (2) Nutrients. 2017 Oct; 9(10): 1063. (3) Nature. 2010;467:1114-1117. (4) Cancer Causes Control. 2010;21:493-500. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-11. (7) Neurology. 2011 Aug 2;77(5):418-25.

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.

Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

June is cataract awareness month. How much do you know about how to reduce your risk?

A cataract is an opacity or cloudiness of the lens in the eye, which decreases vision over time as it progresses. Typically, it’s caused by oxidative stress, and it’s common for both eyes to be affected. As we get older, the likelihood we will have cataracts that affect our vision increases.

In the U.S., 24.4 million people over the age of 40 were afflicted in 2015, according to statistics gathered by the National Eye Institute of the National Institutes of Health (1). Approximately 50 percent of Americans have cataracts by age 75.

Cataract prevalence varies considerably by gender, with 61 percent of cases being women, and by race; 80 percent of those affected are white. Chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity can contribute to your risk. 

The good news is that we can take an active role in preventing them. Protecting your eyes from the sun and injuries, quitting smoking, and increasing your consumption of fruits and vegetables can improve your odds. Here, we will focus on the dietary factor.

How does meat consumption affect cataract risk?

Diet has been shown to have substantial effect on the risk reduction for cataracts (2). One of the most expansive studies on cataract formation and diet was the Oxford (UK) group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

There was an inverse relationship between cataract risk and the amount of meat consumed. In other words, those who ate more meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork. These results followed what we call a dose-response curve.

Compared to high meat eaters, every other group demonstrated a significant risk reduction as they progressed along a spectrum that included low meat eaters (15 percent reduction), fish eaters (21 percent reduction), vegetarians (30 percent reduction) and finally vegans (40 percent reduction).

There really was not that much difference in meat consumption between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. This suggests that you can realize a meaningful effect by reducing or replacing your average meat intake, rather than eliminating meat from your diet.

In my clinical experience, I’ve had several patients experience cataract reversal after they transitioned to a nutrient-dense, plant-based diet. This is a very positive outcome and was confirmed by their ophthalmologists.

Do antioxidants help prevent cataracts?

Oxidative stress is one of the major contributors to cataract development. In a review article that looked at 70 different trials for the development of cataract and/or maculopathies, such as age-related macular degeneration, the authors concluded antioxidants, which are micronutrients found in foods, play an integral part in eye disease prevention (3). The authors go on to say that a diet rich in fruits and vegetables, as well as lifestyle modification with cessation of smoking and treatment of obesity at an early age, help to reduce the risk of cataracts. You are never too young or too old to take steps to protect your vision.

Among antioxidant-rich foods studied that have shown positive effects is citrus. The Blue Mountains Eye Study found that participants who had the highest dietary intake of vitamin C reduced their 10-year risk for nuclear cataracts (4).

How effective is cataract surgery?

The only effective way to treat cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens. This is an outpatient procedure and usually takes about 30 minutes. Fortunately, there is a very high success rate for this surgery. So why is it important to avoid cataracts if surgery can remedy them?

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage, age-related macular degeneration (AMD) after cataract surgery (5). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients.

It has been hypothesized that the surgery may induce inflammatory changes and the development of leaky blood vessels in the retina of the eye. However, this meta-analysis was based on observational studies, so it’s not clear whether undiagnosed AMD may have existed prior to the cataract surgery, since they have similar underlying causes related to oxidative stress.

If you can reduce the risk of cataracts through diet and other lifestyle modifications, plus avoid potential consequences from cataract surgery, all while reducing the risk of chronic diseases, why not choose the win-win scenario?


(1) (2) Am J Clin Nutr. 2011 May; 93(5):1128-1135. (3) Exp Eye Res. 2007; 84: 229-245. (4) Am J Clin Nutr. 2008 Jun; 87(6):1899-1305. (5) Ophthalmology. 2003; 110(10):1960.

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.

Fancy sea salts are not better than regular salt. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Sodium and high blood pressure are often linked in our minds. But what if we don’t have high blood pressure? Does our salt intake matter? According to the Centers for Disease Control and Prevention, about 90 percent of Americans consume too much sodium – and it’s not just about our risk for high blood pressure (1).

Why does sodium matter?

Of course, excessive sodium in our diets increases our risk of high blood pressure (hypertension), which has consequences like stroke and heart disease.

Now comes the interesting part. Even if we don’t have high blood pressure, sodium can impact our kidney function. In the Nurses’ Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a daily sodium intake of 2,300 mg had a much greater chance of a 30 percent or more reduction in kidney function when compared to those who consumed 1,700 mg per day.

Kidneys are an important part of our systems for removing toxins and waste. They are also where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it can be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

How much sodium is too much?

Interestingly, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon. If you’ve been paying attention, you’ve probably noticed that’s the same level that led to negative effects in the study. However, Americans’ average intake is 3,400 mg a day (1).

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

Where we get most of our sodium

Most of our sodium intake comes from processed foods, packaged foods and restaurants, not the saltshaker at home. There is nothing wrong with eating out or ordering in on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains that her clothes and rings are tight.

Do you want to lose 5 to 10 pounds quickly? Decrease your salt intake. Excess sodium causes the body to retain fluids.

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon.

Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Make sure to read the labels on all packaged foods and sauces very carefully, checking for sodium and for serving size.

Breads and rolls are another hidden source. Most contain a decent amount of sodium. I have seen a single slice of whole wheat bread include up to 200 mg. of sodium. That’s one slice.

Soups are also notoriously high in sodium. There are a few packaged soups on the market that have no sodium, such as some Health Valley soups. You can use these and add your own seasonings. Restaurant soups are a definite “no.”

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as cheeses, sweet sauces and salad dressings. I recommend putting all sauces and dressings on the side, so you can control how much — if any — you choose to use.

Is sea salt better than table salt?

Are fancy sea salts better than table salt? High amounts of salt are harmful, and the type is not important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to causing health issues, salt tends to dampen your taste buds, masking the flavors of food.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly so, and you will notice new flavors in unsalted foods.

When seasoning your food at home, use salt-free seasonings, like Trader Joe’s 21 Seasoning Salute or, if you prefer a salty taste, use a salt substitute, like Benson’s Table Tasty.


(1) (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3)

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.

Eating potassium-rich foods may improve your outcomes. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension, also commonly called “high blood pressure,” is pervasive in the U.S., affecting approximately 47 percent of adults over 18 (1). Since 2017, hypertension severity has been categorized into three stages, each with its recommended treatment regimen. 

One of the most interesting shifts with this recategorization was the recategorization of what we used to call “prehypertension” into what we now call “elevated” blood pressure and “hypertension stage 1.” 

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg, while Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of 80-89 mmHg (2). A simple chart of all levels can be found on The American Heart Association’s website at

Both elevated blood pressure and stage 1 hypertension have significant consequences, even though there are often no symptoms. For example, they increase the risks of cardiovascular disease and heart attack dramatically.

In an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (3). This is why it’s crucial to address it, even in these early stages.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (4).

The good news is that, over the last decade, new and extended studies have given us better clarity about treatments, stratifying approaches to ensure the best outcomes.

Do you need to treat elevated blood pressure?

In my view, it would be foolish not to treat elevated blood pressure. Updated treatment recommendations, according to the Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, include lifestyle modifications (5).

Lifestyle changes include dietary changes. A Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet are both options. It’s important to focus on fruits, vegetables, sodium reduction to a maximum of 1500 mg (2/3 of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (6). 

Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (7). Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

Some drugmakers advocate for using medication with those who have elevated blood pressure. The Trial of Preventing Hypertension (TROPHY) suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (8)(9). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Still, the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, which makes the drug. 

In an editorial, Jay I. Meltze, M.D., a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (10). 

Elevated blood pressure has been shown to respond well to lifestyle changes – so why add medication when there are no long-term benefits? I don’t recommend treating elevated blood pressure patients with medication. Thankfully, the JNC8 agrees.

Do lifestyle changes help with Stage 1 hypertension?

For those with Stage 1 hypertension, but with a low 10-year risk of cardiovascular events, these same lifestyle modifications should be implemented for three-to-six months. At this point, a reassessment of risk and blood pressure should determine whether the patient should continue with lifestyle changes or needs to be treated with medications (11). 

It’s important to note that your risk should be assessed by your physician.

I am encouraged that the role of lifestyle modifications in controlling hypertension has been recognized and is influencing official recommendations. When patients and physicians collaborate on a lifestyle approach that drives improvements, the side effects are only better overall health.


(1) (2) (3) Stroke 2005; 36: 1859–1863. (4) Hypertension 2006;47:410-414. (5) Am Fam Physician. 2014 Oct 1;90(7):503-504. (6) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (7) Archives of Internal Medicine 2001;161:589-593. (8) N Engl J Med. 2006;354:1685-1697. (9) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (10) Am J Hypertens. 2006;19:1098-1100. (11) Hypertension. 2021 Jun;77(6):e58-e67.

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.

METRO photo
We should be more concerned about fiber than protein.

By David Dunaief, M.D.

Dr. David Dunaief

Growing up, I often heard admonitions to get enough protein. Even now, I am often asked how to be sure someone is getting enough. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets.

What we should be more concerned about is whether we’re getting enough fiber in our diets. Most Americans are woefully deficient in fiber, consuming between 10 and 15 grams per day. Consumption of legumes and dark green vegetables are the lowest in comparison to other fiber subgroups (1). This has significant implications for our overall health and weight.

So, how much is enough? USDA guidelines stratify their recommendations based on gender and age. For adult women, they recommend between 22 and 28 grams per day, and for adult men, the targets are between 28 and 35 grams (1). Some argue that even these recommendations are on the low end of the scale for optimal health.

Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to increase your fiber consumption; you just have to be aware of which foods are fiber-rich.

Does fiber type make a difference?

One of the complexities is that there are a number of different classifications of fiber, from soluble to viscous to fermentable. Within each of the types, there are subtypes of fiber. Not all fiber sources are equal.

At a high level, we break dietary fiber into two overarching categories: soluble and insoluble. Soluble fibers slow digestion and nutrient absorption and make us feel fuller for longer. Sources include oats, peas, beans, apples, citrus fruits, flax seed, barley and psyllium. On the other hand, insoluble fibers accelerate intestinal transit, which promotes digestive health. Sources include wheat bran, nuts, berries, legumes and beans, dark leafy greens, broccoli, cabbage and other vegetables. 

Many plant-based foods contain both soluble and insoluble fiber, in varying amounts.

Fiber’s effects on disease progression and longevity

Fiber has powerful effects on our overall health. A very large prospective cohort study showed that fiber may increase longevity by decreasing mortality from cardiovascular disease, respiratory diseases and other infectious diseases (2). Over a nine-year period, those who ate the most fiber were 22 percent less likely to die than those in the lowest group.

Patients who consumed the most fiber also saw a significant decrease in mortality from cardiovascular disease, respiratory diseases and infectious diseases. The authors of the study believe that it may be the anti-inflammatory and antioxidant effects of whole grains that are responsible for the positive results.

A study published in 2019 that performed systematic reviews and meta-analyses on data from 185 prospective studies and 58 clinical trials found that higher intakes of dietary fiber and whole grains provided the greatest benefits in protecting participants from cardiovascular diseases, type 2 diabetes, and colorectal and breast cancers, along with a 15-30 percent decrease in all-cause mortality for those with the highest fiber intakes, compared to those with the lowest (3).

We also see benefit with prevention of chronic obstructive pulmonary disease (COPD) with fiber in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities study (4). The specific source of fiber was important. Fruit had the most significant effect on preventing COPD, with a 28 percent reduction in risk. Cereal fiber also had a substantial effect, but it was not as great.

Fiber also has powerful effects on breast cancer treatment. In a study published in the American Journal of Clinical Nutrition, soluble fiber had a significant impact on breast cancer risk reduction in estrogen negative women (5). Most beneficial studies for breast cancer have shown results in estrogen receptor positive women. This is one of the few studies that has illustrated significant results in estrogen receptor negative women.

The list of chronic diseases and disorders that fiber prevents and/or treats is continually expanding.

How do I increase my fiber intake?

Emphasize plants on your plate. Animal products don’t contain natural fiber. These days, it’s easy to increase your fiber by choosing bean- or lentil-based pastas, which are becoming more prevalent in general grocery stores. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice.

If you are trying to prevent chronic diseases in general, I recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages: it helps you avoid processed foods, reduces your risk of chronic disease, and increases your satiety and energy levels.

Certainly, while protein is important, each time you sit down at a meal, rather than asking how much protein is in it, you now know to ask how much fiber is in it.


(1) (2) Arch Intern Med. 2011;171(12):1061-1068. (3) Lancet. 2019 Feb 2;393(10170):434-445. (4) Amer J Epidemiology 2008;167(5):570-578. (5) Amer J Clinical Nutrition 2009;90(3):664–671.

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.

Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

Our assumptions about alcohol and health are complicated and often wrong. Many of you may have heard that Europeans who drink wine regularly live longer because of this. Or that only heavy drinkers need to be concerned about long-term health impacts. Would it surprise you to hear that both assumptions have been studied extensively?

Alcohol is one of the most widely used over-the-counter drugs, and yet there is still confusion over whether it benefits or harms to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing, including cancers, heart disease and stroke.

Alcohol and cancer risk

The National Cancer Institute notes that alcohol is listed as a known carcinogen by the National Toxicology Program of the US Department of Health and Human Services (1). Among the research it details, it lists head and neck, esophageal, breast, liver and colorectal cancers as key cancer risks that are increased by alcohol consumption. Of these, esophageal and breast cancer risks are increased with even light drinking. Let’s look more closely at some of the research on breast cancer risk that supports this.

A meta-analysis of 113 studies found there was an increased risk of breast cancer with daily alcohol consumption (2). The increase was a modest, but statistically significant, four percent, and the effect was seen at one drink or fewer a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increased the risk of breast cancer modestly over a 28-year period (3). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, meaning the more participants drank in a day, the greater their risk increase. In this study, there was no difference in risk by type of alcohol consumed, whether wine, beer or liquor.

Based on what we think we know, if you are going to drink, a drink a few times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes this effect (4).

Alcohol and stroke risk

On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (5). This analysis involved over 83,000 women. Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

However, women who consumed more experienced a decline in benefits, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients should not drink alcohol solely to get stroke protection benefits.

If you’re looking for another option to achieve the same benefits, an analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (6). The citrus fruits used most often in this study were oranges and grapefruits. Note that grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (7).

Alcohol and heart attack risk

In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more and those who were non-drinkers (8). Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits.

What’s the conclusion?

Moderation is the key. It is important to remember that alcohol is a drug, and it does have side effects, including insomnia. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more. To achieve the stroke benefits and avoid increased breast cancer risk, half a glass of alcohol per day may work for women. For men, up to two glasses daily counts as moderate, though one glass showed significant general health benefits. 

If you choose to forgo alcohol, the good news is that there is a growing variety of non-alcoholic beverages entering the market and increasing in popularity.


(1) (2) Alc and Alcoholism. 2012;47(3)3:204–212. (3) JAMA. 2011;306:1884-1890. (4) JAMA. 2011;306(17):1920-1921. (5) Stroke. 2012;43:939–945. (6) Stroke. 2012;43:946–951. (7) (8) Eur Heart J. Published online March 28, 2012.

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.

Osteoarthritis is a risk factor. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Despite the best efforts of public campaigns and individual physicians, heart disease is still the number one cause of death in the U.S. (1). To put that in perspective, every 33 seconds, one person dies of heart disease.

While some risk factors are obvious, others are not. Obvious ones include family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. In addition, age plays a role in risk: men at least 45 years old and women at least 55 years old are at greater risk. Less obvious risks include gout, atrial fibrillation and osteoarthritis. 

The good news is that we have more control than we think. Most of these risks can be significantly reduced with lifestyle modifications.

How much role does weight really play in heart disease risk?

Obesity continually gets play in discussions of disease risk. But how important is it, really?

In the Copenhagen General Population Study, results showed an increased heart attack risk in those who were overweight and in those who were obese – with or without metabolic syndrome, which includes a trifecta of high blood pressure, high cholesterol and high sugar levels (2). “Obese” was defined as a body mass index (BMI) over 30 kg/m², while “overweight” included those with a BMI over 25 kg/m².

Heart attack risk increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome.

It is true that those with metabolic syndrome and obesity together had the highest risk. However, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Because this was an observational trial, the results represent an association between obesity and heart disease. Basically, it’s telling us that there may not be such a thing as a “metabolically healthy” obese patient. If you are obese, this is one of many reasons that it’s critical to lose weight.

Do activity levels really affect heart disease risk?

Let’s consider another lifestyle factor; activity levels. An observational study found that these had a surprisingly high impact on women’s heart disease risk (3). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over age 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported, it may have been underestimated as a risk factor. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

How long should you suffer with osteoarthritis?

The prevailing thought with osteoarthritis is that it is best to live with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? In a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack (4). Those who had surgery for the affected joint saw a substantially reduced heart attack risk. If you have osteoarthritis, it is important to improve mobility, whether with surgery or other treatments. Of course, I have written in previous columns about techniques for managing osteoarthritis.

When does fiber matter most?

Studies show that fiber decreases the risks of heart attack and of death after a heart attack. In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (5).

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is that those who increased their fiber after a cardiovascular event had a 31 percent reduction in mortality risk. The most intriguing part of the study was the dose response. For every 10-gram increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. For perspective, 10 grams of fiber is a little over one cup of raspberries or two-thirds of a cup of black beans or lentils.

How much does lifestyle really affect heart disease risk?

In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events such as heart attacks (6).

We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with modifications that include weight loss, physical activity and diet. While there are many diseases that contribute to heart attack risk, most of them are modifiable.


(1) (2) JAMA Intern Med. 2014;174(1):15-22. (3) Br J Sports Med. 2014, May 8. (4) PLoS ONE. 2014, 9: e91286 (5) BMJ. 2014;348:g2659. (6) N Engl J Med. 2000;343(1):16.

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.

METRO photo
Chest pain is only one of many possible symptoms.

By David Dunaief, M.D.

Dr. David Dunaief

Each year, 805,000 people in the U.S. have heart attacks, or myocardial infarctions —about one every 40 seconds (1). These statistics traverse race and gender lines, even though symptoms may be experienced differently. Outcomes for those having a heart attack are significantly better if they receive immediate medical attention. First, however, you need to recognize the symptoms.

What are symptoms of a heart attack?

The most recognizable symptom is chest pain. However, there are a number of other, more subtle, symptoms such as discomfort or pain in the jaw, neck, back, arms and epigastric, or upper abdominal areas. Others include nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate).

Unfortunately, less than one-third of people know these symptoms (2). About 10 percent of patients present with atypical symptoms — without chest pain — according to one study (3).

It is not only difficult for the patient but also for the medical community, especially the emergency room, to determine who is having a heart attack. Fortunately, approximately 80 to 85 percent of chest pain sufferers are not having a heart attack. More likely, they have indigestion, reflux or other non-life-threatening ailments. However, don’t hesitate to seek immediate medical attention; it’s better to have a medical professional rule out a heart attack than to ignore one.

Are heart attack symptoms different for men and women?

There has been much discussion about whether men and women have different symptoms when it comes to heart attacks. Several studies speak to this topic.

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish study, after having a heart attack, a significantly greater number of women died in the hospital or near-term when compared to men. The women received reperfusion therapy, artery opening treatment that consisted of medications or invasive procedures, less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram. This was a study involving approximately 54,000 heart attack patients, with one-third being women.

One theory about why women receive less aggressive treatment when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. But, is this true? Not according to several studies.

In one observational study of 2,500 patients with chest pain, results showed that, though there were some subtle differences, when men and women presented with this main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: the duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. The population difference was a conspicuous weakness of an otherwise solid study, since age and previous heart attack history are important factors.

In the GENESIS-PRAXY study, another observational study, the median age of both men and women was 49. Results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings, significantly more were women than men.

Those who did not have chest pain symptoms may have experienced back discomfort, weakness, discomfort or pain in the throat, neck, right arm and/or shoulder, flushing, nausea, vomiting and headache. If the patients did not have chest pain, regardless of sex, the symptoms were diffuse and nonspecific. 

Some studies imply that as much as 35 percent of patients do not present with chest pain as their primary complaint (7).

What should you do if someone is having a heart attack?

Call 911 immediately, and have the patient chew an adult aspirin (325 mg) or four baby aspirins, provided they do not have a condition that precludes taking aspirin. The purpose of aspirin is to thin the blood quickly, but not if the person might have a ruptured blood vessel. The 911 operator or emergency medical technician who responds can help you determine whether aspirin is appropriate.

What are the most frequently occurring heart attack symptoms to watch for?

Most patients have chest pain, and both men and women have similar types of chest pain. However, this is where the simplicity stops and the complexity begins. The percentage of patients who present without chest pain seems to vary significantly depending on which study you review — ranging from less than 10 percent to 35 percent.

Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. It’s important to recognize heart attack symptoms, since quick action can save your life or that of a loved one.


(1) Circulation. 2022;145(8):e153–e639. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA. 2012;307:813-822.

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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Proton pump inhibitors should be taken at the lowest dose for the shortest possible time.

By David Dunaief, M.D.

Dr. David Dunaief

Sometimes referred to as “reflux” or “heartburn,” Gastroesophageal reflux disease (GERD) is one of the most treated diseases in the U.S. Technically, heartburn is a symptom of GERD, so this is a bit of a misnomer.

Proton pump inhibitors (PPIs), first launched in 1989, have become one of the top-10 drug classes prescribed or taken over-the-counter (OTC). PPIs currently available OTC include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), and Aciphex (rabeprazole). These and others are also available by prescription.

Their appeal among physicians has been their possible role in the reduction of esophageal cancer resulting from Barrett’s Esophagus. Interestingly, recent studies note that this perceived benefit may not be real (1).

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

However, their OTC availability can lead patients to take them too long or too often to manage reflux rebound effects when PPIs are discontinued without physician oversight. In addition, some existing medical risks are heightened by PPIs. 

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

PPIs and the kidneys

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

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

Increased dementia risk

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

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk. Researchers also did not take into account high blood pressure, excessive alcohol use or family history of dementia, all of which influence dementia occurrence.

Increased fracture risk

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

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

Vitamin absorption issues

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

A second study, a meta-analysis of nine studies, confirmed these results: PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (9). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

Another study’s results showed long-term use of over two years increased vitamin B12 deficiency risk by 65 percent (10).

The bottom line

It’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as an H2 blocker (Zantac, Pepcid). In addition, PPIs may interfere with other drugs you are taking, such as Plavix (clopidogrel).

Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (11).

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


(1) PLoS One. 2017; 12(1): e0169691. (2) (3) JAMA Intern Med. 2016;176(2). (4) JAMA Intern Med. 2016;176(2):172-174. (5) JAMA Neurol. online Feb 15, 2016. (6) Osteoporos Int. online Oct 13, 2015. (7) Am J Med. 118:778-781. (8) PLoS Med. 2014;11(9):e1001736. (9) Ren Fail. 2015;37(7):1237-1241. (10) Mayo Clinic Proceedings. 2018 Feb;93(2):240-246. (11) Am J Gastroenterol 2015; 110:393–400.

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