Medical Compass

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Diet composition and fitness trump (severe) calorie restriction in benefits

You would think that all of us, if given a choice, would want to live longer. However, in a recent informal survey involving 30,000 participants over the last three years, more than half did not want to live past the 80-year current life expectancy for developed countries ( Aug. 25). This would be surprising, except that the most frequent reason offered had to do with not wanting to be old and debilitated. What if we could propose improving longevity — and health — so that people would feel vivacious throughout their lives, regardless of age?

Calorie restriction impact
Recent thinking has been that if we restrict our calorie intake significantly, by 30 percent, then we are more apt to live longer and healthier lives. That is what we were led to believe by earlier studies in monkeys, like the 2009 University of Wisconsin study (Science. 2009 Jul 10;325(5937):201-4). The problem with the study was that the researchers discounted a number of monkeys who died, claiming this did not have to due with aging.

However, a newly published study with rhesus monkeys reported different results (Nature online Aug. 29). Severely restricting these monkeys’ calories did not increase their longevity, nor did they live healthier lives. These results were disappointing in that calorie restriction is not necessarily the panacea that we thought. This was a 25-year study and the results had been eagerly anticipated.

There were some benefits to calorie restriction, though. For older males and females, heart disease risk was reduced due to lowered triglyceride levels. This was true, ironically, only when calorie restriction was begun when the monkeys were already old.

However, the monkeys — calorie restricted or not — did still experience chronic diseases such as heart disease and cancer.

What about chronic disease?

It appears that chronic disease is the greatest hindrance to achieving or maintaining a better quality of life. Coincidently, the Centers for Disease Control and Prevention has released data that show chronic disease is on the rise, with increasing numbers of patients having two or more diseases. Also, it appears that the United States lags behind European nations in reducing the number of preventable deaths, called “amenable mortality.” Most of these deaths are caused by chronic disorders, such as high blood pressure, stroke and cancers. The U.S. is seeing a decline in its rates of preventable deaths but at half the pace of France and the United Kingdom. So what can we do to slow the rise in chronic disease and accelerate the decrease in our rate of preventable deaths?

Diet composition effect

Dietary choices can have a tremendous effect on health. Not surprisingly, poor diet composition is one of the leading contributors to many chronic diseases such as high cholesterol, diabetes and heart disease, and thus amenable mortality rates (Ann Intern Med 2010;153:736-750). The CDC showed that only about one-quarter of Americans consumed the most basic levels of fruits and vegetables recommended.

However, there are several diets that have been promoted because they are known to have powerful effects on reversing this dismal trend of increasing chronic disease such as the DASH diet and the Mediterranean-type diet. In 2010, the DASH diet was highlighted because of its beneficial effects on prevention and treatment of disease ( At the basis of this diet is the emphasis on nutrient-rich foods, including fruits, vegetables, nuts and seeds, beans and legumes, and whole grains, as well as a modest amount of lean animal protein.

The DASH diet was originally designed to lower blood pressure. In a randomized controlled trial, the gold standard of studies, DASH showed significantly lower systolic blood pressure results compared to those on a standard diet, even though both groups were intentionally given the same level of sodium intake, which is very interesting (N Engl J Med 1997;336:1117-1124). The difference was that DASH increased the amounts of fruits, vegetables and low-fat dairy, while lowering saturated fat.

Subsequent prospective studies, such as the Nurses’ Health Study, have borne out the benefits of the DASH diet in lowering heart disease risk in patients followed for a 25-year duration (Arch Intern Med 2008;168:713-720).

Fitness at any age — a greater impact than expected

We used to think that fitness helped delay disease, but a new study suggests that fitness in middle age, defined as people in their 50s, actually decreased the risk of chronic disease significantly. It didn’t just delay it (Arch Int. Med online Aug. 27). Ultimately, fitness at any age seems to provide us with a higher quality of life. This study involved 18,600 participants. There was an approximately 45 percent reduction across the board for both men and women in incidence of the top eight chronic diseases.
The good news is that you may not have to make yourself miserable by eating a very low calorie diet in the hopes of achieving a longer life.

Rather than suffering — or imagining suffering — through severe calorie restriction, why not focus on consistent, modest fitness routines and diets that are rich in nutrients and high in volume? The potential disease-modifying effects could play a crucial role in preventing what we perceive as age-related decline. Then, you can have a positive attitude toward living longer, since you will be able to maintain, if not improve, your health as you age.

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

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There may be contradictions with obesity, but risks far outweigh benefits

When studies have unexpected results, I feel the need to investigate further.
In life we run into paradoxes all the time. A paradox is defined as a statement or opinion that seems to contradict itself. For instance, “You should not go near the water until you learn to swim” is a paradox. You can’t learn to swim until you get in the water.

There are two recent apparent medical contradictions, both obesity paradoxes. One refers to heart attacks and the other to type 2 diabetes.

Obesity paradox in heart attacks

A newly published meta-analysis involving two studies finds that obese patient are more likely to survive a heart attack at year one than are patients who have a normal body mass index, known as BMI (Am J Med. 2012 Aug;125(8):796-803).

In other words, the results show that a patient’s risk of mortality from a heart attack is inversely related to weight. Those who were obese had the lowest mortality rate from a heart attack: 4.7 percent. Those who were overweight had a 6.1 percent mortality rate, and those with normal weight had a 9.2 percent mortality rate. This is a paradox. It’s logical to assume the higher the weight the higher the risk of mortality, but that isn’t the case.

Although the reasons were unknown, the authors surmise that this effect may occur because obese and overweight patients seek medical attention with their symptoms earlier than normal weight patients. Overweight and obese patients may have a heighten awareness of their heart attack risk.

So what do we do about the paradox? At face value the study would seem to imply that it is better to be obese, because your prognosis may be better after suffering a heart attack. However, if you look below the surface, it is a more complex issue. Obese patients may be at higher risk for all-cause mortality and
cardiovascular disease.

Obesity’s impact on all-cause mortality

Obesity was found to increase the risk of all-cause mortality. This was demonstrated in a very large observational study, The Nurses’ Health Study, which showed a linear relationship with risk. Patients who were overweight had a 30 to 60 percent increased chance of all-cause mortality, while obese patients had over a 200 percent increased risk of death (N Engl J Med. 1995;333(11):677). Also, gaining 22 pounds or more after age 18 resulted in increased risk of all-cause mortality in middle age.

Obesity and cardiovascular risk

Obesity seems to be an independent risk for heart disease beyond high blood pressure, high cholesterol and type 2 diabetes, according to the American Heart Association (Circulation. 2006;113(6):898).

The Framingham Heart Study, a large observational study, showed a statistically significant increased risk for cardiovascular disease in both overweight and obese patients, with some patients followed for as long as 44 years (Arch Intern Med. 2002;162(16):1867). Those who were obese had the highest risk, with a 46 percent increase in men and 64 percent increase risk in women.

Obesity and fatal heart attacks

In an observational study following men over approximately 15 years, obesity in middle-aged men significantly increased their risk of death from heart attacks (Heart 2011;97:564-568). Interestingly, this study, just like the obesity paradox study, controlled for other risk factors, and even with these taken into account, the men had a 60 percent greater risk of dying from a heart attack. The authors suggest the reason is that inflammation underlies obesity’s effects.

The obesity paradox in type 2 diabetes

There were counterintuitive results in a recent meta-analysis, involving a group of five studies, with participants who became type 2 diabetes patients during the study (JAMA. 2012;308:581-590). The patients who were normal weight were two times more likely to see an increase in total mortality compared to patients who were obese. There was no significance difference in cardiovascular mortality.

The authors could not explain why there was a higher mortality in normal weight patients except to hypothesize that it may have to do with inflammation, pancreatic beta cell functioning and/or the extent of plaque development in the arteries. However, only 11 percent of patients who had type 2 diabetes were of normal weight, whereas 89 percent were overweight or obese.

It is interesting because more than 80 percent of cases of type 2 diabetes are associated with obesity ( Some in the medical field have taken to calling the phenomenon “diabesity.” This study reinforces that notion. Even though the normal weight patients had a higher mortality rate, the overall risk of developing type 2 diabetes was much higher in obese patients.

In the accompanying editorial to the diabetes study, the author refers to diabetes patients of normal weight as MONW (that is, metabolically obese normal weight) individuals (JAMA. 2012;308(6):619-620).These are obviously not healthy patients, despite their BMIs being in the normal range. The author recommends healthy weight loss — an alteration in body composition so that there is a loss of fat mass and an increase in lean body mass. This, she suggests, can occur with a Mediterranean-type diet and exercise.

The caveat with normal weight

Normal weight does not necessarily equal health. It is a paradigm that is long overdue for a shift. I hear people say all the time that this person is thin, so he or she must be healthy, and we know that is not necessarily true.

Chronic diseases occur in patients of all different BMIs — cancers, heart disease, autoimmune diseases and even diabetes — although weight may exacerbate or increase risk. The scary part is that almost one quarter of patients in the U.S. are metabolically abnormal, according to the Third National Health and Nutrition Examination Survey (Arch Intern Med. 2008;168(15):1617-1624).

The moral of the story is that it’s important to read between the lines in some studies. Whatever you do, know that there are many complications that are associated with obesity.

Just because there may be an apparent benefit to obesity, there are more downsides. Thin or normal weight does not imply fit or lean body mass. Monitoring body composition changes in combination with a healthy lifestyle is the best defense against getting caught up in the aforementioned paradoxes.

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

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Caffeine and omega-3 fatty acids may help treat the disease

Dry eye disease (keratoconjunctivitis sicca) is not always dry. Paradoxically, one of its symptoms may be excessive tearing. Other symptoms may include burning, stinging, itching, light sensitivity, dryness, blurred vision and foreign body sensation (Arch Ophthalmol. 2009;127:763-768).Dry eye is a result of either increased tear evaporation or decreased tear production.

Inflammation may play a role in causing or exacerbating dry eye, although the causes are not completely clear. It is associated with chronic diseases, such as diabetes and Sjögren’s syndrome. Some medications such as some antihistamines, some antidepressants, some sleeping pills and some blood pressure medications may also be contributing factors.

Dry eye is very common, affecting approximately 3.9 percent of men between the ages of 50 and 54. Its prevalence doubles to 7.7 percent as men reach 80 years old, according to the Physicians’ Health Study (Arch Ophthalmol. 2009;127(6):763-768). Sixty-six percent of dry eye disease occurs in women and also increases with age (Am J Ophthalmol. 2003;136(2):318-326). While we can’t reduce the risk from aging, this is only one of many factors.

There are a number of risk factors that are modifiable. Diet is one of them, since patients with dry eye may have low vitamin A and low omega-3 fatty acid levels. Vitamin A comes from foods like carrots and broccoli, and omega-3 fatty acids are in fish, nuts, seeds and fish oil. These deficiencies are easily rectifiable and should not go unnoticed.

Treatments of dry eye

There are a variety of treatments for dry eye, ranging from using artificial tears, consuming omega-3 fatty acids and potentially caffeine to the use of topical medications that reduce inflammation, such as cyclosporine and tofacitinib (in the early phases of development) to the placement of punctal plugs in the tear ducts — a minor procedure to block tear drainage.

The impact of omega-3 fatty acids

Why are omega-3 fatty acids important? Omega-3 fatty acids may work, at least partially, by blocking factors that increase inflammation, such as interleukin-1 and tumor necrosis factor-alpha. In the Women’s Health Study, involving 32,470 participants, those who were in the highest intake group for omega-3 fatty acids had a significantly decreased risk of developing dry eye disease, compared to those with the lowest intake of fatty acids (Am J Clin Nutr 2005;82:887-893).

But even more impactful was that those women with the highest ratio of omega-6 (pro-inflammatory) to omega-3 (anti-inflammatory) fatty acids had an increased risk of dry eye that was more than 2.5-fold greater than those with a much lower ratio of less than 4:1.

Interestingly, in the standard American diet that most of us eat, the ratio of omega-6 to omega-3 is about 20:1, whereas with a high nutrient, plant-rich diet, the ratio hovers around the optimal greater than 4:1 ratio.

Fish oil supplementation types: triglyceride vs. ethyl ester

The type of fish oil may also make a difference when supplementing with omega-3 fatty acids. A triglyceride formulation is the natural form of fish oil. In a study, it seems that the triglyceride formulation is absorbed to a greater extent than the ethyl ester formulation, which may translate into better results with treating dry eye (Biochem Biophys Res Commun. 1988 Oct 31; 156(2):960-3). Patients may be able to decrease the dose, and thus potential side effects, with the triglyceride formulation. To boost omega-3 levels, take fish oil with a meal containing some good fats. Eating fish may be the best way to get the natural triglyceride formulation (Lipids. 2003;38:415-418).

Caffeine effects

In a small double-blind crossover trial (meaning both groups in the study will eventually consume caffeine), caffeine appears to increase the capability of the dry eye patient to increase tear production (Ophthalmology. 2012 May;119(5):972-8). This may help overcome the symptoms of dry eye for patients. Caffeine seemed to increase the amount of tears in the eye — by 30 percent. There were 78 participants in the study, and it was only two sessions long, spanning a six day interval. Though the results are impressive, more study is obviously needed. Daily caffeine intake also seemed to have an impact on increasing tear production.

Disease association and inflammation

It makes sense that dry eye is associated with diabetes, rheumatoid arthritis and Sjögren’s syndrome — the latter two being autoimmune diseases — because these diseases have inflammatory components. In a study, there was a linear association between the risk of dry eye and diabetes (BMC Ophthalmology, June 2008). In other words, the longer patients had diabetes, the higher the probability of having dry eye disease. Also, patients who had diabetic retinopathy, a complication of diabetes affecting the back of the eye, were at greater risk of developing dry eye. This is just another reason that it is so important for diabetes patients to keep their blood glucose levels under control with lifestyle modifications and/or medications. Diabetic retinopathy occurs when blood sugar levels are too high on a chronic basis.

Thus, though dry eye is a common malady, there are a variety of ways to treat the disorder. It is important to not only get enough omega-3s, but also to optimize the ratio of omega-6 to omega-3s. This will only happen if patients embrace a nutrient-rich diet. Consult your ophthalmologist for the most effective treatment for you. However, increasing omega-3s with diet is only beneficial so it won’t hurt to embrace dietary changes.

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

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Vitamin D levels may be inversely related to disability in M.S. patients

Medicine has made great strides in the treatment of multiple sclerosis over the last few decades.
M.S. is an autoimmune disease, where there is underlying inflammation and the immune system attacks its own tissue. This causes demyelination, or breakdown of the myelin sheath, a protective covering on the nerves in the central nervous system. The result is a number of debilitating effects, such as cognitive impairment, numbness and weakness in the limbs, fatigue, memory problems and inflammation of the optic nerve causing vision loss and eye pain (optic neuritis), and mobility difficulties.

There are several forms of M.S.. The two most common are relapsing-remitting and primary-progressive. Relapsing-remitting has intermittent flare-ups and occurs about 85 percent to 90 percent of the time. Primary-progressive (steady) occurs about 10 percent of the time. Relapsing-remitting may eventually become secondary-progressive M.S., which is much harder to control, although dietary factors may play a role.

Diagnosis and progression

M.S. is diagnosed in several ways. The ophthalmologist may be the first to diagnose the disease with a retinal exam (looking at the back of the eye). If you have eye pain or sudden vision loss in one eye, it is important to see your ophthalmologist.

Another tool in diagnosis is an MRI of the central nervous system. This looks for lesions caused by the breakdown of the myelin sheath.

The MRI can also be used to determine the risk of progression from a solitary CNS lesion to a full-blown M.S. diagnosis. This is accomplished by examining the corpus callosum, a structure deep within the brain, according to a recent presentation at the European Neurologic Society (Abstract O-293; June 2012).

Approximately half of patients with one isolated lesion will progress to clinically definite M.S. within six years. An MRI may be able to predict changes in this portion of the brain within two years. Patients with a family history of M.S. should discuss this diagnostic with a neurologist.


Interferon beta is the mainstay of treatment for M.S. for good reason. Data shows that it reduces recurrence in relapsing-remitting M.S. and also the number of brain lesions.

However, in a recent study, interferon beta failed to stop the progression to disability in the long term (JAMA. 2012;308:247-256). Many M.S. patients will experience disability over 20 years. Ultimately, what does this mean? Patients should continue therapy, however they should have realistic expectations. This study was retrospective, looking back at previously collected data — not the strongest of studies.

Vitamin D impact

Vitamin D may play a key role in reducing flare-ups in relapsing-remitting M.S.. There were several studies that showed this benefit with vitamin D supplements and/or with interferon beta.
In one study, interferon beta had very interesting results showing that it may help increase the absorption of vitamin D from the sun (Neurology. 2012;79:208-210). This was a randomized controlled trial, the gold standard of studies, involving 178 patients. The study’s authors suggest that interferon beta’s effectiveness at reducing the frequency of relapsing-remitting M.S. flare-ups may have to do with its effect on the metabolizing of vitamin D.

In those who did not have higher blood levels of vitamin D, interferon beta actually increased the risk of flare-ups. Physicians should monitor blood levels of vitamin D to make sure they are adequate. It may be beneficial for M.S. patients to get 15 to 20 minutes of sun exposure without sunscreen per day. However, patients with a history of high risk of skin cancer should not be in the sun without protective clothing and sunscreen.

In a prospective (forward-looking) observational study, patients with higher levels of vitamin D, even in those without interferon beta treatment, had reduced risk of relapsing-remitting M.S. flare-ups (Neurology. 2012;79:254-260).The patients with higher levels had 40 ng/ml, and those with lower levels had 20 ng/ml. Patients’ blood samples were assessed every eight weeks for a mean duration of 1.7 years. The relationship with vitamin D was linear — as the blood level increased two-fold, the risk of flare-ups decreased by 27 percent.

In an RCT, higher levels of vitamin D in the blood showed a trend toward reduced disability in timed tandem walking and in disability accumulation (J Neurol Neurosurg Psychiatry. 2012;83(5):565-571). The results did not reach statistical significance, but approached it. A much larger RCT needs to be be performed to test for significance.

Diet and lifestyle

Interestingly, a recent study found that caffeine, alcohol and fish — fatty or lean — intake may result in delay of secondary progression of relapsing-remitting M.S. (Eur J Neurol. 2012 Apr;19(4):616-24). This observational study involved 1,372 patients. The reduction in risk of disability was as follows: moderate daily alcohol intake resulted in a 39 percent reduction; daily coffee consumption showed a 40 percent reduction; and fish two or more times a week showed a 40 percent reduction. All of these results were compared to patients who did not consume these items. However, the same effect was not shown in primary-progressive M.S. patients: fatty fish actually increased risk of progression, compared to lean fish.

With M.S., vitamin D blood levels may be critically important. They are one of the easier fixes, although it may take higher doses of vitamin D supplementation to reach sufficient levels, once low. While food (fish with bones, for example) provides vitamin D, it falls short of the amount needed by an M.S. patient. Interferon beta and vitamin D supplementation may have added effects. Lifestyle changes or additions also have tantalizingly appealing possibilities.

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

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You don’t need to be an Olympian to get gold medal results

I am inspired by the 30th Olympiad to discuss the implications of exercise. It would be nice if we could all be in the shape of Olympians, but most of us simply hope that, if we exercise more, we will burn more calories and lose more weight. However, there is a new study addressing this assumption, and the results are disappointing.

Does this mean we should give up exercise, or that exercise has little impact on our lives? The answer is a resounding “no.” We have to look beyond weight loss, just as we do when considering the differences in diets — as I did in last week’s article — to disease prevention and modification.

We know that exercise can alter the course of many chronic diseases, including the top 10 diseases responsible for killing many Americans, including diabetes, heart disease, stroke and cancer. I am going to focus on diabetes treatment and prevention, highlighting several recent studies.

Weight loss and exercise

The presumption has always been that if we exercise, we will lose weight equivalent to the amount of effort that we put into the activity. But, as many of us have experienced, we lose weight at a slower rate than predicted, maintain our weight or even continue to gain weight. Why is this?

In a study, anthropologists looked at a tribe in Tanzania to try to explain why exercise does not seem to reduce weight to the degree that we would expect (PLoS One. 2012;7(7):e40503). They followed the Hadza tribe — hunter and gatherers — for 11 days with GPS, tracking how active they were and their metabolic rates. While they were more active than most Americans — seven miles a day for men and three miles a day for women — they did not have a higher resting metabolic rate. In other words, they were not burning more calories. Their bodies seemed to adapt.

The authors, therefore, surmise that exercise cannot overcome the typical western high-calorie diet. This seems to be reinforced by another study that concluded the same thing about calorie-dense diets being hard to overcome (Obes Rev. 2012 Jun 11). For those of you who think that exercise is a pass to eat what you want, think again.

Also, lower body mass burns fewer calories for the same level of effort. For example, if my wife and I get on two treadmills with the same settings and for the same period of time, since I weigh more, I burn more calories than she does.

The researchers who investigated the Hadza tribe, did not look at weight-lifting or resistance training and their impacts on body composition. As we build muscle, it may be hard to lose weight. A pound of muscle, while weighing the same as a pound of fat, has a higher density. So you can be fit without losing as much weight as you replace fat with muscle. Just look at those Olympians.

Weight-lifting impact

Resistance training seems to have more of an impact on body composition. In a randomized controlled trial of women, ages 25 to 44, participants who were in the treatment group saw a significantly greater reduction in body fat percentage than the control group, at 3.8 percent and 0.14 percent respectively (Am J Clin Nutr. 2007 Sep;86(3):566-72). The treatment group followed a regimen of strength training twice a week, compared to the control group, who were given brochures for aerobic exercise.

Aerobic and anaerobic impact on diabetes

In a meta-analysis (a group of studies, including a very large prospective observational study called EPIC), patients who had diabetes at baseline and were physically active had a much lower risk of dying from cardiovascular disease and a significant reduction in total mortality, compared to those who were least active (Arch Intern Med. online August 6, 2012). Interestingly, the group that did moderate amounts of activity daily saw the largest reductions in overall mortality and death due to cardiovascular disease, at 38 percent and 49 percent respectively. Therefore, you don’t have to be an Olympian to get gold medal results in preventing complications from diabetes.

There were also surprisingly inspiring results with short durations of exercise in diabetes. Three short anaerobic exercise bouts of 10 minutes each daily were potentially more efficacious in helping to control glucose levels in diabetes patients, compared to 30 minutes once a day, as the results showed in a small randomized controlled trial (Diabetologia. 2007 Nov;50(11):2245-53).

Intensity did not seem to be as important as duration in preventing diabetes. In the Health Professionals Follow-up Study, 150 minutes a week of strength training or aerobic exercise are critical to reducing diabetes risk (Arch Intern Med. online August 6, 2012), at 34 percent and 52 percent respectively. The greatest reduction in risk was when participants did a combination of strength and aerobic activities within the 150 minutes.

So the message ultimately is that putting on lean body mass by weight lifting may be a more effective way to change body composition than aerobic exercise alone. And aerobic exercise has tremendous benefits in treating and preventing chronic disease, even in moderate amounts done in short bursts. Ideally, lifestyle modifications should include both exercise and diet in order to reach weight-loss goals.

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

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A low-carbohydrate, high-protein diet may increase cardiovascular disease risk

The hotly debated topic about the importance of diet type was in the news recently. In terms of weight loss, a calorie may be a calorie. However, in terms of its effect on body composition, disease modification and prevention, this may not be true. Some diets may have more beneficial or detrimental effects on health than others.

A low-carb, high-protein and high-fat diet

There was a recent study that showed a low-carbohydrate, high-protein diet was more effective at burning calories after initial weight loss than other diets (JAMA 2012 Jun 27; 307:2627). In this study, patients were given a 12-week “washout period” where they lost 10 to 15 percent of their body weight. They were then put on three different diets and assessed over a four-week period with each: a low glycemic index diet, a low-fat diet and a very low-carbohydrate diet.

The diet that seemed to show the most benefit for maintaining weight loss was the very low-carbohydrate diet, which was high in protein and high in fat — an Atkins-type diet. This diet lowered the resting energy expenditure the least, meaning that the body burned calories more efficiently. Patients expended 300 more calories on this low-carbohydrate diet than on the low-fat diet and 150 more calories than on the low glycemic index diet. This study was a prospective (forward-looking) randomized crossover trial involving 21 young obese and overweight adults; each participant was on each diet for a month. However, the study’s duration may be too short to tell us anything meaningful.

Why did the low-carbohydrate diet show the best results for maintaining weight loss and burning more calories? This question was answered in the Science Times section of The New York Times on July 9 by Dr. Jules Hirsch, emeritus physician in chief at Rockefeller University. He has a background that includes 60 years of obesity research, and he believes that the difference seen with the Atkins-type diet was due to water loss. He says that, ultimately, weight loss is dependent on the traditional formula — the amount of calories consumed minus the amount of calories burned on a daily basis — not the diet’s composition. He aptly points out, however, that diets’ compositions are important, because they affect patients’ overall health.

Low-carb, high-protein diet negative effects

Ironically, another study published the same week as the JAMA study showed a potentially increased risk of cardiovascular disease with a low-carbohydrate, high-protein diet (BMJ 2012 Jun 26; 344:e4026). The study was a prospective trial involving 43,396 Swedish women with a 15.7 year duration. There was a 4 percent increase in risk for every 10 percent increase in protein or, as the authors point out, for every additional boiled egg consumed. This is a modest, yet harmful, effect.

Low-carb, high-protein diets have also shown an increased risk of kidney stones. There was a doubling of uric acid levels in the kidney and a significant increase in urine calcium levels over a six-week period (Am J Kidney Dis. 2002 Aug;40(2):265-74). The weaknesses of this study are that it was small, 10 participants, and short in duration. However, it does make you think that low-carb, high-protein diets from animal sources may not be the best option for overall health.

Interestingly, another study showed that a low-carb, high-protein diet may vary in its effects, depending on the source of protein (Ann Intern Med 2010;153:289-298). If high protein levels and fat came from animal sources, then there was an increased risk of death from heart disease and cancer — 14 percent and 28 percent respectively. However, if the protein and fat came from plant sources, such as nuts and beans, the risks of all-cause mortality and mortality from cardiovascular disease were decreased by 20 percent and 23 percent, respectively, over the same length of time. The study was a meta-analysis (a group of two studies) that included the Nurses’ Health Study, with over 85,000 women, and the Physicians’ Health Study, with approximately 45,000 men, with a duration of 26 years and 20 years of follow up, respectively.

Mediterranean diet’s effect on body composition

We know a Mediterranean-type diet has profound effects on risk reduction for many diseases (BMJ 2008;337:a1344). Recently, I had a patient who began a nutrient-rich, plant-based diet with an incremental approach. After one month of having altered one meal a day, the patient lost two pounds.
However, this was not the whole story. Using a clinical-trial-grade body composition scale, I found that the patient had lost 10 pounds of fat mass, 4 percent body fat and had gained 7 pounds of fat-free mass, most of it water, without having exercised during the month. This demonstrates that a diet can do far more than alter body weight.

No one will argue that weight loss is important, especially for those patients who are obese. However, when looking at a diet, it is important to also consider its effectiveness for disease treatment and prevention. Diets that are considered to be most effective include a Mediterranean-type diet, the DASH diet, the Ornish diet and any other diet that is plant-based and nutrient-rich. Why lose weight for vanity only, when you can lose weight and gain health at the same time?

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

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Weight loss and dietary changes have resounding effects on symptoms

Menopause is a physiologic process that affects all women, not a pathologic or disease-based one. The problem is that vasomotor symptoms, such as hot flashes, flushes and night sweats, can have an adverse effect on most women who are perimenopausal (around menopause) or postmenopausal. Approximately 80 percent of women report having these symptoms, with half experiencing moderate to severe symptoms.

Symptoms last, on average, between one and five years, though they may persist longer than a decade. Unfortunately, many women suffer through them without treatment.

According to a recent study, there are also increased cardiovascular risks in women who experience early menopause, occurring before the age of 46. Early menopause increases the risk of heart attacks and strokes twofold. The authors suggest the best way to lower risk may be to follow general preventive measures for reducing the risk of heart disease (Menopause. online June 11, 2012).

Are there viable treatment options to alleviate menopausal symptoms? The answer is yes, and we will look at some of these options including lifestyle modifications, hormone therapy and soy products.

Lifestyle modifications

In the Women’s Health Initiative Dietary Modification Trial, a large, randomized trial, the combination of weight loss and diet played a significant role in reducing or eliminating vasomotor symptoms in 90 percent of menopausal women (Menopause. online July 9, 2012).

When women lost more than 10 percent of their body weight, they were 56 percent more likely to eliminate vasomotor symptoms when compared to women who were in the control group and did not lose weight. This is impressive, but the results get even better. When dietary modifications were combined with greater than 10 percent weight loss, nearly nine out of 10 women saw an elimination of symptoms.

The design of the trial involved a low-fat diet with 20 percent of calories from fat, plus five servings of fruits and vegetables and an increase in fiber from whole grains to six servings daily.

This diet made it more than three times as likely that women would lose weight compared to the control group. The study involved over 17,000 women who were not on hormone therapy for menopausal symptoms. Thus, the results were purely due to weight loss and dietary changes.

Hormone therapy

Hormone therapy has been a hotly debated topic in recent years. The Women’s Health Initiative is one of the trials that prompted this debate, with unexpectedly negative results showing increased risk of stroke, heart attack, deep vein thrombosis and pulmonary embolism. However, there may be more to the story. This has to do with timing, personal history and dosage.

In a consensus statement by 15 medical organizations, short-term hormone therapy is thought to be safe for the treatment of vasomotor symptoms, depending on the woman’s health history, age and when menopause commenced (Menopause. online July 9, 2012).

Of note, the American College of Obstetricians and Gynecologists was not part of this consensus statement. Patients need to make an informed decision with their OB/GYN to determine if the benefits outweigh the risks on an individualized basis. For healthy women younger than 59 or within 10 years of the beginning of moderate-to-severe vasomotor symptoms, low-dose hormone therapy may be appropriate.

In March, the FDA approved a combination low-dose hormone therapy of 0.25 mg progestin and 0.50 mg estrogen called drospirenone/estradiol ( for the treatment of hot flashes and night sweats. It reduced the frequency by two episodes a day at four weeks and by three episodes a day by 12 weeks. However, there are side effects, and it is contraindicated in several circumstances, the most severe being increased risk of stroke. Do not consider this medication without consulting your OB/GYN first.

Soy effect

Soy may have benefit in terms of brain functioning. In preliminary results, soy and soy isoflavones (nutrients from soy) have shown to potentially improve cognitive function in early menopause, something that hormone therapy is not approved for (Menopause. 2011; 18(7);732-753). This effect is lost on women who are older than 65 when soy is first given. In other words, there is an ideal window for treatment, much like there is with hormone therapy. For more about soy, see my March 8 article.

Soy products have had mixed results in treating vasomotor symptoms. In a recent meta-analysis (a group of 17 studies), soy supplements reduced hot flashes in menopausal women by a modest 21 percent (Menopause. online March 19, 2012). They are thought to have weakly estrogenic effects. When they did occur, hot flashes tended to be milder. The authors suggest that if no results are seen within four weeks, then it is unlikely that soy will affect hot flashes.

The choices are numerous. Lifestyle modifications appear to have the greatest beneficial impact, and the side effects are beneficial for the treatment and prevention of other diseases, as well. Soy may also be of benefit, especially with cognitive aspects. There is really no downside to adopting a nutrient-rich dietary approach.

Hormone therapy is an individual choice that should made in partnership with an OB/GYN. Women should not have to struggle through perimenopausal symptoms negatively impacting their quality of life because they were spooked by past treatment studies.

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

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Supplements of iron and calcium may increase risk

Glaucoma is the second-leading cause of blindness in the world, behind cataracts. It is neurodegenerative (deterioration of the optic nerve) with increased intraocular pressure (IOP) — pressure inside the eye — as an indicator that nerve damage is more likely. The most common types of glaucoma are open angle and angle closure, with the majority of cases in the United States being the former.

Glaucoma initially causes peripheral vision loss and then works its way inward to the central vision. If untreated, it can lead to irreversible blindness (Lancet. 2004;363(9422):1711). Fortunately, there are treatments that revolve around reducing eye pressure, such as prostaglandins and beta blockers.
The occurrence of this disease is rising, with a current 2.8 million Americans affected and a predicted level of 3.4 million in the U.S. by 2020.

Risk factors include age — starting at 40, although those over 65 have higher risk and those over 80 have the highest risk — and race, with African-Americans at a three-times higher risk than those of European ancestry. For African-Americans, it is the No. 1 cause of blindness. In the Baltimore Eye Survey, a family history of the disease dramatically increased risk, with siblings having greater probability than offspring of developing the disease (Arch Ophthalmol. 1994;112(1):69). Finally, the higher the IOP, the greater the risk for progression in open-angle glaucoma (Ophthalmology. 2007;114(10):1810).

The effect of increased visual field-testing

In the Advanced Glaucoma Intervention Study, it was found that visual field-testing by an ophthalmologist every six months for patients at higher risk was better at predicting disease progression than annual testing (Arch Ophthalmol. 2011;129(12):1521-1527). The result was that, with more frequent testing, the researchers were 50 percent more likely to detect progression of the disease, if it were to occur.
Interestingly, the U.S. Preventive Services Task Force currently does not recommend screening for open-angle glaucoma, since it feels there is insufficient evidence (Ann Fam Med. 2005;3(2):171). Whether it updates the results based on this study, only time will tell. The American Academy of Ophthalmology recommends screening every three to five years starting at age 40, with increased frequency — every one to two years — starting at age 60. More frequent screening is recommended for those younger than 60 who have more risk factors (AAO Pub 1996).

Prevention steps

There are several steps that may be valuable, including reducing chronic diseases associated with glaucoma such as type 2 diabetes, Alzheimer’s and erectile dysfunction. If we reduce their incidence, there may also a reciprocal decline in glaucoma.
In addition, avoiding or reducing supplementation with iron and calcium, while potentially increasing magnesium, may decrease incidence of the disease.

Diabetes and high blood pressure

In a analysis of two studies, diabetes increased the risk of open-angle glaucoma by greater than 200 percent (Br J Ophthalmol. 2012;96(6):872-876). In the same analysis, however, systemic hypertension (high blood pressure) increased the risk by a meager 7 percent. This yet another reason we need to control or prevent diabetes, aside from diabetic retinopathy (disease of the back of the eye).

Erectile dysfunction association

Those with erectile dysfunction (had an almost threefold increased risk of also having open-angle glaucoma, compared to those without the disorder (Ophthalmology 2012;119:289-293). There may be vascular symptoms associated with open-angle glaucoma as demonstrated by the increased association with ED. The study suggests that the mechanism of action that both disorders have in common is endothelial dysfunction (inner lining of the blood vessels), which involves a decreased level of nitric oxide, a potent vasodilator, which enables the vessels to expand and relax. ED was also associated with high cholesterol and blood pressure, heart disease and diabetes. It is not unusual to find that many diseases have a common underlying pathology. I wrote an article about the impact of ED on Aug. 11, 2011, that gives more detail on the disorder.


In an abstract presented at the American Glaucoma Society, supplementation with calcium and iron, looked at separately, increase risk of normal-tension glaucoma (NTG), glaucoma without increased pressure (AGS 2012 abstract 22). The calcium and iron came from a variety of sources, including antacids, multivitamins, prescription and nonprescription supplements.

The results showed that participants who took a composite of 800 mg daily of calcium were at an almost 2.5-times increased risk. Those who took 18 mg of iron on a daily basis were at an even higher risk, 3.8 times, of developing the disease. When taken together, iron and calcium increased risk by a resounding 7.2 fold. The study did not look at dietary sources for iron and calcium.

The good news is that a dose of 300 mg of magnesium citrate in patients with NTG showed a benefit in visual field over one month, compared to those who did not take magnesium (Eur J Ophthalmol. 2010;20(1):131-135). Although this was a randomized-controlled trial, it was also very small with only 30 patients.

While there are risk factors — such as family history, age and ethnicity — that can’t be changed, there are a number of modifiable factors as well. Glaucoma may be brought on by factors that are related to those causing systemic diseases. Therefore, it’s important to maintain good health overall to reduce the risk for glaucoma and its irreversible affects.

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

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Supplements may help, depending on the joint affected

Osteoarthritis (or OA) affects half of those over 60, significantly impacting quality of life for 27 million Americans. Historically, the disorder was thought to be solely a wear-and-tear degeneration of the joint(s). However, OA also involves inflammation with the release of cytokines and prostaglandins — inflammatory factors — which cause joint destruction and pain (Rheumatology. 2011;50(12):2157-2165).

The joints most commonly affected include the ankle, knee, hip, spine and hand. OA may affect joints asymmetrically, meaning that it affects a joint on only one side of the body.

One of the mainstays of treatment includes analgesics (painkillers), including acetaminophen and NSAIDs, such as ibuprofen (Advil), naproxen sodium (Aleve) and COX-2 inhibitors (Celebrex). These drugs may also improve joint mobility and NSAIDs have anti-inflammatory effects. There are adverse effects with NSAIDs, including increased gastrointestinal (or GI) bleed and, with long-term use, an increase in cardiovascular events, such as heart attacks, with the elderly being most susceptible. With chronic NSAID use, PPIs (acid-blocking drugs) may be appropriate to avoid GI tract complications (BMC Family Practice 2012;13:23).

Neither medication type, however, structurally modifies the joints. In other words, they may not slow OA’s progression nor rebuild cartilage or the joint space as a whole. Are there therapies that can accomplish these feats and, if so, what are they? We will look at hyaluronic acid, glucosamine and chondroitin, and lifestyle modifications such as exercise and weight loss.

Chondroitin sulfate beneficial for hand OA

The results with the use of glucosamine and chondroitin have been mixed, depending on the joints affected. In the FACTS trial, a randomized controlled trial, chondroitin sulfate by itself showed significant improvement in pain and function with OA of the hand (Arthritis Rheum. 2011 Nov;63(11):3383-91). The dose of chondroitin used in the study was 800 mg once a day. The patients, all of whom were symptomatic at the trial’s start, also saw the duration of their morning stiffness shorten.

There was also a modest reduction in structural damage of hand joints, compared to placebo. The benefit was seen with prescription chondroitin sulfate, so over-the-counter supplements may not work the same way. Patients were allowed to use acetaminophen, and there was no change in dose or frequency throughout the trial. An effect was seen within three months.

Crystalline glucosamine sulfate

In knee OA, crystalline glucosamine sulfate showed reduction in pain and improvement in functioning in an RCT (Ther Adv Musculoskel Dis. 2012;4(3):167-180). When assessed by radiologic findings, it also slowed the progression of structural damage to the knee joint. In other words, the therapy may have disease-modifying effects over the long term. The glucosamine formulation may work by inhibiting inflammatory factors such as NF-kB. The trial used 1500 mg of prescription crystalline glucosamine sulfate over a three-year period. Again, it’s not clear whether an over-the-counter supplement works the same way.

Glucosamine and/or chondroitin for knee OA

In a meta-analysis (group of 10 studies), glucosamine, chondroitin or the combination did not show beneficial effects — reduced pain or mobility changes — in patients when compared to placebo (BMJ. 2010;341:c4675). It was not clear whether supplemental or prescription-level therapies were used in each trial — or whether that makes a difference. This study was published prior to the crystalline glucosamine sulfate trial of the knee, discussed above, which did show statistical significance.

There is not much downside to using glucosamine and/or chondroitin for OA patients. However, use caution if taking an anticoagulant (blood thinner) like Coumadin, since glucosamine has anticoagulant effects. Also, those with shellfish allergies should not use glucosamine. If there is no effect within three months, it is unlikely that glucosamine and/or chondroitin are beneficial.

Hyaluronic acid

In a meta-analysis (a group of 89 trials), the risks outweighed the benefit of hyaluronic acid, a drug injected into the joint for the treatment of OA (Ann Intern Med. online June 12, 2012). Viscosupplementation involves a combination of hyaluronic acid types that act as a shock absorber and lubricant for the joints. Some of the studies did show a clinical benefit. However, the authors believe that adverse local events, which occurred in 30 to 50 percent of patients, and serious adverse events, with 14 trials showing a 41 percent increased risk, outweigh the benefits. Since there are mixed results with the trials, it is best to discuss this option with your physician.

Impact of weight loss and exercise

No matter where you look, obesity is involved in many chronic diseases. OA is no exception. Obesity treatment with a weight-loss program actually has potential disease-modifying affects (Ann Rheum Dis. 2012;71(1):26-32). It may prevent cartilage loss in the medial aspect of the knee. The good news is that, even with as little as a 7 percent weight loss in the obese patient, these results were still observed. The average weight loss was nine to 10 pounds. It was a dose-response curve — the greater the weight loss, the thicker the knee cartilage.

There was a separate study done with computer modeling showing that obesity reduces quality of life by 12 percent and that OA has a negative impact on the quality of life by about the same amount. Interestingly, the combination decreases the quality of life by 25 percent (Ann Intern Med. 2011; 154(4):217-26). Losing weight would also reduce the number of knee replacements, according to the study.

According to Dr. David Felson, a rheumatologist at Boston University School of Medicine who commented in The New England Journal of Medicine, there is an inverse relationship between the amount of muscle-strengthening exercise, especially of the quadriceps, and the amount of pain experienced in the knee joint. It is very important to do nonimpact exercises such as leg raises, squats, swimming, bicycling and on elliptical machines.

Fortunately, there are a number of options to prevent, treat and potentially modify the effects of OA. With weight loss in the obese patient, quality of life can dramatically increased. Glucosamine and/or chondroitin may be of benefit, depending on the joints affected. The benefits are potential improvements in pain, mobility and structural-modifying effects, which are worth the risk for many patients. When taking glucosamine and/or chondroitin in supplement form, may be a good source for finding a supplement where you get the dose claimed on the box. I would also use formulations in the trials that showed results, even in supplement form.

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

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Vitamin D may reduce risk in skin cancer patients; mixed cardiovascular results

Vitamin D is one the most widely publicized and important supplements. We get vitamin D from the sun, food and supplements. Since summer is now in full swing and the beaches are open, I thought it would be appropriate to share some recent findings.

Vitamin D has been thought of as an elixir for life, but is it really? There is no question that, if you have low levels of vitamin D, repleting (replacing) it is important. Previous studies have shown that vitamin D may be effective in a wide swath of chronic diseases, both in prevention and as part of the treatment paradigm. However, many questions remain. As more data come along, their meaning for vitamin D becomes murkier.

The sun

For instance, is the sun the best method to get Vitamin D?
At the 70th annual American Academy of Dermatology meeting, Dr. Richard Gallo who was involved with the Institute of Medicine recommendations, spoke about how, in most geographies, sun exposure will not correct vitamin D deficiencies. Interestingly, he emphasized getting more vitamin D from nutrition. Dietary sources include cold-water, fatty fish such as salmon, sardines and tuna.

We know its importance for bone health, but as of yet, we only have encouraging — but not yet definitive — data for other diseases. These include cardiovascular and autoimmune diseases and cancer.

There is no consensus on the ideal blood level for vitamin D. The Institute of Medicine recommends more than 20 ng/dl, and The Endocrine Society recommends at least 30 ng/dl. More experts and data lean toward the latter number.

Skin cancer

Vitamin D did not decrease non-melanoma skin cancers (known as NMSCs), such as squamous cell and basal cell carcinoma. It may actually increase them, according to one study done at a single center by an HMO (Arch Dermatol. 2011;147(12):1379-84). The results may be confounded, or blurred, by UV radiation from the sun, so vitamin D is not necessarily the culprit. Most of the surfaces where skin cancer was found were sun exposed, but not all of them.

The good news is that, for postmenopausal women who have already had an NMSC bout, vitamin D plus calcium appears to reduce its recurrence, according to the Women’s Health Initiative study (J Clin Oncol. 2011 Aug 1;29(22):3078-84). In this high-risk population, the combination of supplements reduced risk by 57 percent. Unlike the previous study, vitamin D did not increase the incidence of NMSC in the general population. NMSC occurs more frequently than breast, prostate, lung and colorectal cancer combined (CA Cancer J Clin. 2009;59(4):225-49).

Cardiovascular mixed results

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. For example, the Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (Circulation. 2008 Jan 29;117(4):503-11).

However, a recent small randomized controlled trial, the gold standard of studies, calls the cardioprotective effects of vitamin D into question (PLoS One. 2012;7(5):e36617). This study of postmenopausal women, using biomarkers, such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2500 IUs. Thus, one couldn’t argue that this dose was too low. Some of the weaknesses of the study were a very short duration of four months, its size — 114 participants — and the fact that cardiovascular events or deaths were not used as study endpoints. However, these results do make you think.

Weight benefit

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (J Womens Health (Larchmt). 2012 Jun 25).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.

Mortality decreased

In a recent meta-analyses (a group of eight studies), vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (J Clin Endocrinol Metabol. online May 17, 2012). The difference between the groups was statistically important, but clinically small: 9 percent reduction with vitamin D plus calcium and 7 percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large boluses (amounts) of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

USPSTF recommendations

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women the combination of vitamin D 400 IUs plus calcium 1000 mg to prevent fractures (AHRQ Publication No. 12-05163-EF-2). It does not seem to reduce fractures and increases the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

Need for clinical trials

We need clinical trials to determine the effectiveness of vitamin D in many chronic diseases, since it may have beneficial effects in preventing or helping to treat them (Endocr Rev. 2012 Jun;33(3):456-92). Right now, there is a lack of large randomized clinical trials. Most are observational, which gives associations, but not links. The VITAL trial is a large RCT looking at the effects of vitamin D and omega 3s on cardiovascular disease and cancer. It is a five-year trial, and the results should be available in 2016.

When to supplement?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it may play an integral role with many disorders.

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