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Medical Compass

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We should dedicate 33 percent of our lives to sleep to improve brain health. Stock photo

By David Dunaief, M.D.

The brain is the most important and complex organ, yet what we know about the brain is inverse to its prominence. In other words, our knowledge only scratches the surface. While other organs can be transplanted readily, it is the one organ that can’t, at least not yet.

The brain also has something called the blood-brain barrier. This is an added layer of small, densely packed cells, or capillaries, that filter what substances from the blood they allow to pass through from the rest of the body (1). This is good, since it protects the brain from foreign substances; however, on the downside, it also makes it harder to treat, because many drugs and procedures have difficulty penetrating the blood-brain barrier.

Unfortunately, there are many things that negatively impact the brain, including certain drugs, head injuries and lifestyle choices. There are also numerous disorders and diseases that affect the brain, including neurological (dementia, Parkinson’s, stroke), infectious (meningitis), rheumatologic (lupus and rheumatoid arthritis), cancer (primary and secondary tumors), psychiatric mood disorders (depression, anxiety, schizophrenia), diabetes and heart disease.

These varied diseases tend to have three signs and symptoms in common: they either cause an alteration in mental status — cognitive decline, weakness or change in mood – or a combination of these.

Probably our greatest fear regarding the brain is cognitive decline. We have to ask ourselves if we are predestined to this decline, either because of the aging process alone or because of a family history, or if there is a third option, a way to alter this course. Dementia, whether mild or full-blown Alzheimer’s, is cruel; it robs us of functioning. We should be concerned about Alzheimer’s because 5.2 million Americans have the disease, and it is on the rise, especially since the population is aging (2).

Fortunately, there are several studies that show we may be able to choose the third option and prevent cognitive decline by altering modifiable risk factors. They involve rather simple lifestyle changes: sleep, exercise and possibly omega-3s. Let’s look at the evidence.

The impact of clutter

The lack of control over our mental capabilities as we age is what frightens us the most since we see friends, colleagues and relatives negatively affected by it. Those who are in their 20s seem to be much sharper and quicker. But are they really?

In a recent study, German researchers found that educated older people tend to have a larger mental database of words and phrases to pull from since they have been around longer and have more experience (3). When this is factored into the equation, the difference in terms of age-related cognitive decline becomes negligible. This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something. We may need a reboot just like a computer. This may be possible through sleep and exercise and omega-3s.

Sleep

I have heard people argue that sleep gets in the way of life. Why should we have to dedicate 33 percent of our lives to sleep? There are several good reasons. One involves clearing the mind, and another involves improving our economic outlook.

For the former, a study shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (4). When we have excessive plaque buildup in the brain, it may be a sign of Alzheimer’s. This study was done in mice. When mice were sleeping, the interstitial space (the space between brain gyri, or structures) would increase by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough because cerebrospinal fluid could reach much further into the spaces. When the mice were anesthetized, a similar effect was seen as with sleeping.

In a published follow-up study, the authors found that sleep position had an impact on glymphatic transport in rodents. Sleeping in a lateral position, or on their sides, was more effective at clearing waste than prone or supine positions. Of course, the authors note that for rodents a prone position is similar to their awake positions. It would be most like a human sleeping while sitting upright (5).

In another study, done in Australia, results showed that sleep deprivation may have been responsible for an almost 1 percent decline in gross domestic product for the country (6). The reason is obvious: People are not as productive at work when they don’t get enough sleep. Their attitude tends to be more irritable, and concentration may be affected. We may be able to turn on and off sleepiness on an acute, or short-term, basis, depending on the environment, but it’s not as if we can do this continually.

According to the Centers for Disease Control and Prevention, an average of 4 percent of Americans report having fallen asleep in the past month behind the wheel of a car (7). I hope this hammers home the importance of sleep.

Exercise

How can I exercise, when I can’t even get enough sleep? Well there is a study that just may inspire you to exercise.

In the study, which involved rats, those that were not allowed to exercise were found to have rewired neurons in the area of their medulla, the part of the brain involved in breathing and other involuntary activities. There was more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (8). In those rats that were allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart.

This is intriguing since we used to think that our brain’s plasticity, or ability to grow and connect neurons, was finite and stopped after adolescence. This study’s implication is that a lack of exercise causes unwanted new connections. Of course, these results were done in rats and need to be studied in humans before we can make any definitive suggestions.

Omega-3 fatty acids

In the Women’s Health Initiative Memory Study of Magnetic Resonance Imaging Study, results showed that those postmenopausal women who were in the highest quartile of omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (9). The hippocampus is involved in memory and cognitive function.

Specifically, the researchers looked at the level of omega-3 fatty acids, called eicosapentaenoic acid and docosahexaenoic acid, in red blood cell membranes. The source of the omega-3 fatty acids could either have been from fish or supplementation. This was not delineated. The researchers suggest eating fish high in these substances, such as salmon and sardines, since it may not even be the omega-3s that are playing a role but some other substances in the fish. It’s never too late to improve brain function. You can still be sharp at a ripe old age. Although we have a lot to learn about the functioning of the brain, we know that there are relatively simple ways we can positively influence it.

References: (1) medicinenet.com. (2) alz.org. (3) Top Cogn Sci. 2014 Jan.;6:5-42. (4) Science. 2013 Oct. 18;342:373-377. (5) J Neurosci. 2015 Aug 5;35(31):11034-11044. (6) Sleep. 2006 Mar.;29:299-305. (7) cdc.gov. (8)J Comp Neurol. 2014 Feb. 15;522:499-513. (9) Neurology. 2014;82:435-442. Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

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Hormone replacement can have serious consequences. Stock photo

By David Dunaief, M.D.

We are bombarded continually with ads suggesting that men should talk to their doctors about “Low T.” This refers to low testosterone. Is this all hype, or is this a serious malady that needs medical attention? The short answer is it depends on the candidate. The best candidates have deficient testosterone levels and are symptomatic.

Men do go through andropause or have unusually low testosterone (hypogonadism). The formal name for treatment is androgen replacement therapy.

The greatest risk factor for lower testosterone is age. As men age, the level of testosterone decreases. Respectively, 20, 30 and 50 percent of those who are in their 60s, 70s and 80s have total testosterone levels of less than 320 ng/dL (1). However, some of the pharmaceutical ads would have you think that most men over 40 should seek treatment. Treatments offered include gels, transdermal patches and injections.

While real estate is all about “location, location, location,” with testosterone “caution, caution, caution” should be used.

Who are the most appropriate candidates for therapy? Those who have symptoms including lack of sexual desire, fatigue and lack of energy. However, what is scary is that around 25 percent of patients are getting scripts for testosterone without first testing their blood levels to determine if they have a deficiency (2). A simple blood test can measure total testosterone, as well as free and weakly bound levels at mainstream labs.

The number of testosterone scripts increased threefold from 2001 to 2011 for men more than 40 years old (3). Either we have discovered vast numbers of men with low levels or, more likely, marketing has caused the number of scripts to outstrip the need.

What are the risks and benefits of treating testosterone levels? Is testosterone treatment really the fountain of youth? There are benefits reported for those who actually have significantly deficient levels. Benefits may include improvements in muscle mass, strength, mood and sexual desire (4). However, several studies have suggested that testosterone therapy may increase the risk of cardiovascular disease, including stroke, heart disease and even death. These are obviously serious side effects. It also may cause acquired hypogonadism by shrinking the testes, resulting in a dependency on exogenous, or outside, testosterone therapy.

When testosterone is given, it may be important to also test PSA levels (5). If they increase by more than 1.4 ng/ml over a three-month period, then it may be wise to have a discussion with your physician about considering discontinuing the medication. You should not stop the medication without first talking to your doctor, and then a consult with a urologist may be appropriate. If the PSA is greater than 4.0 ng/ml initially, treatment should probably not be started without a urology consult.

How can you raise testosterone levels and improve symptoms without hormone therapy? Lifestyle changes, including losing weight, exercising and altering dietary habits, have shown promising results. Let’s look at the evidence.

Cardiovascular risk

One study’s results showed that men were at significantly increased risk of experiencing a heart attack within the first three months of testosterone use (6). There was an overall 36 percent increased risk. When stratified by age, this was especially true of men who were 65 and older. This population had a greater than twofold risk of having a heart attack. This risk may have to do with an increased number of red blood cells with testosterone therapy. Those who were younger showed a trend toward increased risk but did not meet statistical significance.

When the patient was younger than 65 and had heart disease, there was a significant twofold greater risk of a heart attack; however, those without heart disease did not show risk. This does not mean there is no risk for those who are “healthy” and younger; it just means the study did not show it. This observational study compared over 50,000 men who received new testosterone scripts with over 150,000 men who received scripts for erectile dysfunction drugs: phosphodiesterase type 5 (PDE5) inhibitors, including tadalafil (Cialis) and sildenafil (Viagra). PDE5 inhibitors have not demonstrated this cardiovascular risk.

Unfortunately, this is not the only study that showed potential cardiovascular risks. A 2013 study reinforced these results, showing that there was an increased risk of stroke, heart attack and death after three years of testosterone use (7). Ultimately, it found a 30 percent greater chance of cardiovascular events. What is worse is that risk was significant in both those with a history of heart disease and those without. This was a retrospective study involving 1,200 men with a mean age of 60.

We need randomized controlled trials to make a more definitive association. Still, these are two large studies that suggest increased risk. If you already have heart disease, be especially careful when considering testosterone therapy.

FDA response

The FDA, which approved testosterone therapy originally, is now investigating the possible cardiovascular risk profile based on the above two studies (8). The FDA doesn’t suggest stopping medication if you are taking it presently, but it should be monitored closely. The agency, in the meantime, has issued an alert to doctors about the potential dangerous side effects of androgen replacement therapy. The FDA says that the use of testosterone therapy is for those with low levels and other medical issues, such as hypogonadism from either primary or secondary causes.

Conflicting data

Two newer studies contradict the previous findings and suggest that testosterone supplementation for those who are deficient may not increase the risk of cardiovascular events or death. However, both studies have their weaknesses. One found that, although the cardiovascular events and death increased over the first two months, over the medium (9 months) and long terms (35 months), the risks actually decreased (9). Weaknesses: There was an initial detrimental cardiovascular effect; the study was observational; and the population was not well-defined as to participants’ history of cardiovascular disease or not. The second study was retrospective or backward-looking in time (10). These studies may not change the FDA warnings. What we need is a large randomized controlled trial.

Obesity and weight loss

Not surprisingly, obesity is an important factor in testosterone levels. In a study that involved 900 men with metabolic syndrome — borderline or increased cholesterol levels, sugar levels and a waist circumference greater than 40 inches — those who lost weight were 50 percent less likely to develop testosterone deficiencies. Those who participated in lifestyle modification had a highly statistically significant 15 percent increase in testosterone (11). Also, when men increased their physical activity and made dietary changes, there was an almost 50 percent risk reduction one year out, compared to their baseline at the start of the trial.

Interestingly, metformin had no effect in preventing lower testosterone levels in patients with abnormal sugar levels, but lifestyle modifications did. These patients were relatively similar to the average American biometrics with prediabetes: HbA1c of 6 percent and glucose of 108 mg/dL; a mean of 42-inch waists; and a BMI that was obese at 32 kg/m2. The mean age was between 53 and 54.

If there is one thing that you get from this article, I hope it’s that testosterone is not something to be taken lightly. You can improve testosterone levels if you’re overweight by losing fat pounds. If you think you have symptoms and you might need testosterone, talk to your doctor about getting a blood test before you do anything. It may be preferable to try alternate medications that improve erections such as sildenafil and tadalafil.

References: (1) J Clin Endocrinol Metab. 2001 Feb;86(2):724. (2) J Clin Endocrinol Metab. Online 2014; Jan 1. (3) JAMA Intern Med. 2013 Aug 12;173(15):1465-1466. (4) J Clin Endocrinol Metab. 2000 Aug;85(8):2839. (5) UpToDate.com. (6) PLoS One. 2014 Jan 29; 9(1):e85805. (7) JAMA. 2013;310:1829-1836. (8) FDA.gov. (9) Lancet Diabetes Endocrinol. 2016;4(6):498-506. (10) Eur Heart J. 2015;36(40):2706-2715. (11) ENDO 2012; Abstract OR28-3.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Trying to avoid triggers for migraines can be worse than navigating a minefield. Stock photo

By David Dunaief, M.D.

Migraines are a debilitating disorder. Symptoms typically include nausea, photophobia and phonophobia — sensitivity to light and to sound, respectively. The corresponding headache usually is unilateral and has a throbbing or pulsating feeling.

Migraines typically last anywhere from four to 72 hours, which is hard to imagine. Then, there is a postdrome recovery period, when the symptoms of fatigue can dog a patient for 24 hours after the original symptoms subside. Migraines are among the top reasons patients see a neurologist (1).

According to the American Migraine Foundation, there are approximately 36 million migraineurs, the medical community’s term for migraine sufferers. This has increased from 23.6 million in 1989. Women are three times more likely to be affected than men (2), and the most common age range for migraine attacks is 30 to 50 (3), although I have seen them in patients who are older.

What causes a migraine?

The theory was once simple: It was caused by vasodilation (enlargement) of the blood vessels. However, this may only be a symptom, and there are now other theories, such as inflammation of the meninges (membrane coverings of the brain and spinal cord). As one author commented, “Migraine continues to be an elephant in the room of medicine: massively common and a heavy burden on patients and their healthcare providers, yet the recipient of relatively little attention for research, education, and clinical resources” (4). There are many potential triggers for migraines, and trying to avoid them all can be worse than navigating a minefield. Triggers include stress, hormones, alcohol, caffeine, diet, exercise, weather, odor, etc. (5).

Focusing on prevention

There are many problems with treating acute migraine attacks beyond the obvious patient suffering. Eventually, patients may increase tolerance to drugs, needing more and more medication until they reach the maximum allowed. There are also rebound migraines that occur from using medication too frequently — more than 10 days in the month — including with acetaminophen (Tylenol) and NSAIDs (6). There are several options for preventive paradigms, some of which include medication, supplements, alternative therapies and dietary approaches.

Medication’s role

There are several classes of medications that act as a prophylaxis for episodic (less than 15 days per month) migraines. These include blood pressure and anti-seizure medications, botulinum toxin (botox) and antidepressants (7).

Blood pressure control itself reduces the occurrence of headaches (8). The data is strongest for beta blockers. Propranolol, a beta blocker, has shown significant results as a prophylaxis in a meta-analysis (group of studies) involving 58 studies where propranolol was compared to placebo or compared to other drugs (9). However, it showed only short-term effects. Also, there were a substantial number of dropouts from the studies.

Topiramate, an anti-seizure medication, showed a significant effect compared to placebo in reducing migraine frequency (10). In a randomized control trial (RCT) that lasted six months, there was a dose-response curve; the higher the dose, the greater the effect of the drug as a prophylaxis. However, drugs come with side effects: fatigue, nausea, numbness and tingling. The highest recommended dose is 100 mg because of side effects. As a result, almost one-third or 30 percent of patients cease therapy at the 200-mg dose because of side effects (11).

Botulinum toxin type A injection has not been shown to be beneficial for preventive treatment of episodic migraines but has been approved for use as a prophylaxis in chronic (greater than 15 days per month) migraines. However propranolol, mentioned already, has shown better results with fewer adverse reactions (12).

Alternative approaches

Butterbur, an herb from the butterbur (Petasites hybridus) root, was beneficial in a four-month RCT for the prevention of migraine (13). The 150-mg dose, given in two 75-mg increments, reduced the frequency of migraine attacks by almost twofold compared to placebo. This herb was well tolerated, with burping the most frequent side effect. Only Petasites’ commercial form should be ingested; the plant contains pyrrolizidine alkaloids, which may be a carcinogen and seriously damage the liver.

Feverfew, another herb, but this time the leaves are used for medicinal purposes, unfortunately, had mixed prophylaxis results. In a meta-analysis, study authors concluded that feverfew was not more beneficial than placebo (9). And, the most significant caveat with herbal medications is that their safety is not regulated by the FDA nor by any officially sanctioned regulatory body.

What about supplements?

High-dose riboflavin, also known as vitamin B2, may be an effective preventive measure. In a small RCT, 400 mg of riboflavin decreased the frequency of migraine attacks significantly more than placebo (14). The number of days patients had migraines also decreased. The side effects were mild for both placebo and riboflavin. Thus, this has potential as a prophylaxis, though the trial, like most of those mentioned above, was relatively short.

How about diet and exercise?

From my experience and those of other physicians, such as Dr. Joel Fuhrman and Dr. Neal Bernard, nutrient-dense foods are potentially important in substantially reducing the risk of migraine recurrence. I have seen many patients, both in my practice and in the three years I worked with Dr. Fuhrman, do much better, if not recover. There are a number of foods that are unlikely to cause migraine and reduce their occurrence, such as cooked green, orange and yellow vegetables, some fruits — though not citrus fruits — certain nuts, beans and brown rice. The number of foods can be expanded over time.

Interestingly, endogenous (from within the body) and exogenous (from outside the body, such as preservatives) toxins cause high levels of free fatty acids and blood lipids that are triggers for migraine (15). Higher fat diets and high levels of animal protein have been associated with more migraines. In addition, obesity may increase the frequency and severity of migraines (16).

Also, there was a small randomized controlled trial that showed exercise with 40 minutes of cycling three times a week may be comparable to medication for migraine prevention (17). Thus, there are several options for preventing migraines. The most well studied are medications; however, the most effective may be dietary changes and exercise, which don’t precipitate the rebound migraines that medication overuse may cause. And the herb butterbur may be an option as well.

References: (1) uptodate.com Sept. 2011. (2) Headache. 2001;41(7):646. (3) Medscape.com. (4) Annals of Neurology 2009;65(5):491. (5) Cephalalgia. 2007;27(5):394. (6) Headache. 2006;46 Suppl 4:S202. (7) uptodate.com. (8) Circulation. 2005;112(15):2301. (9) Cochrane Database Syst Rev. 2004. (10) JAMA. 2004;291(8):965-973. (11) CMAJ. 2010;182(7):E269. (12) Prescrire Int. 2011;20(122):287-290. (13) Neurology. 2004;63(12):2240. (14) Neurology. 1998;50(2):466-470. (15) J Women’s Health Gend Based Med. 1999;8(5):623-630. (16) Obes Rev. 2011;12(5):e362-371. (17) Cephalalgia. 2011;31(14):1428-1438.

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, visit www.medicalcompassmd.com or consult your personal physician.

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By losing just 10 pounds, you can prevent deadly illness, alleviate daily pain and improve your quality of life. Stock photo

By David Dunaief, M.D.

Some research shows that obesity may be reaching a plateau. Is this true? It depends on how the data is analyzed. According to one study, yes; it has plateaued when looking at short, two-year periods from 2003 to 2011 (1).

However, another published study shows a picture that is not as positive (2). The study’s authors believe obesity has not plateaued; when looking over a longer period of time, statistics suggest that obesity has reached a new milestone. There are now more obese patients in the United States than there are overweight patients. And no, it is not because we have fewer overweight patients. This is based on a study that reviewed data from the National Health and Nutrition Examination Survey (NHANES). These results were in adults over the age of 20. This should be an eye-opener.

Unfortunately, according to one study, the probability is not very good for someone to go from obese to “normal” weight in terms of body mass index (3). In this observational trial, results show that an obese man has a 0.5 percent chance of achieving normal weight, while a woman has a slightly better chance, 1 percent. This study used data from the UK Clinical Practice Datalink. The data were still not great for men and women trying to achieve at least a 5 percent weight loss, but better than the prior data. Patients who were more obese actually had an easier time losing 5 percent of their body weight.

What are two major problems with being obese? One, obesity is a disease in and of itself, as noted by the American Medical Association in 2013 (4). Two, obesity is associated with — and is even potentially a significant contributor to — many chronic diseases such as cardiovascular disease (heart disease and stroke), high blood pressure, high cholesterol, atrial fibrillation, diabetes, cancer, cognitive decline and dementia. When I attended the 28th Blackburn Course in Obesity Medicine in June 2015 at Harvard Medical School, a panel of experts noted that there are over 180 chronic diseases associated with obesity.

In this article, we will focus on one significant multifaceted disease, cancer. Watch out for cancer One of the more unpredictable diseases to treat is cancer.

What are the risk factors?

Beyond family history and personal history, obesity seems to be important. In fact, obesity may be a direct contributor to 4 percent of cancer in men and 7 percent of cancer in women (5). This translates into 84,000 cases per year (6). On top of these stunning statistics, there is about a 50 percent increased risk of death associated with cancer patients who are obese compared to those with normal BMIs (7).

What about with breast cancer?

The story may be surprising and disappointing. According to an analysis of the Women’s Health Initiative, those who were obese had increased risks of invasive breast cancer and of death once the diagnosis was made (8). The severity of the breast cancer and its complications were directly related to the severity of the obesity. There was a 58 percent increased risk of advanced breast cancer in those with a BMI of >35 kg/m2 versus those with normal BMI of <25 kg/m2. And this obese group also had a strong association with estrogen-receptor-positive breast cancer.

However, those who lost weight did not reduce their risk of breast cancer during the study. There were 67,000 postmenopausal women between the ages of 50 and 79 involved in this prospective (forward-looking) study. The researchers do not know why patients who lost weight did not reduce their risk profile for cancer and suggest the need for further studies. This does not imply that lifestyle changes do not have a beneficial impact on breast cancer.

What can we do?

We find that fat is not an inert or static substance, far from it. Fat contains adipokines, cell-signaling (communicating) proteins that ultimately may release inflammatory factors in those who have excessive fat. Inflammation increases the risk of tumor development and growth (9).

There is a potentially simple step that obese cancer patients may be able to take — the addition of vitamin D. In a study in older overweight women, those who lost weight and received vitamin D supplementation were more likely to reduce inflammatory factor IL-6 than those who had weight loss without supplementation (10). This was only the case if the women were vitamin D insufficient. This means blood levels were between 10 and 32 ng/mL to receive vitamin D.

Interestingly, it has been suggested that overweight patients are more likely to have low levels of vitamin D, since it gets sequestered in the fat cells and, thus, may reduce its bioavailability. Weight loss helps reduce inflammation, but the authors also surmise that it may also help release sequestered vitamin D. The duration of this randomized controlled trial, the gold standard of studies, was one year, involving 218 postmenopausal women with a mean age of 59.

All of the women were placed on lifestyle modifications involving diet and exercise. The treatment group received 2,000 IU of vitamin D3 daily. Those women who received vitamin D3 and lost 5 to 10 percent of body weight reduced their inflammation more than those in the vitamin D group who did not lose weight.

What does medicine have to offer?

There are a host of options ranging from lifestyle modifications to medications to medical devices to bariatric surgery. In 2015, the FDA approved two medical devices that are intragastric (stomach) balloons (11). The balloons are filled with 500 mL of saline after inserting them in the stomach via upper endoscopy. They need to be removed after six months, but they give the sense of being satiated more easily and help with weight loss.

One, the ReShape Dual Balloon, is intended to go hand-in-hand with diet and exercise. It is meant for obese patients with a BMI of 30-40 kg/m2 and a comorbidity, such as diabetes, who have failed to lose weight through diet and exercise. In a randomized controlled trial involving 326 obese patients, those who received the balloon insertion lost an average of 14.3 lb in six months, compared 7.2 lb for those who underwent a sham operation.

Lifestyle modifications

In an ode to lifestyle modifications, a study of type 2 diabetes patients showed that diet helped reduce weight, while exercise helped maintain weight loss for five years. In this trial, 53 percent of patients who had initially lost 23 lb (9 percent of body weight) over 12 weeks and maintained it over one year were able to continue to maintain this weight loss and preserve muscle mass through diet and exercise over five years (12). They also benefited from a reduction in cardiovascular risk factors. In the initial 12-week period, the patients’ HbA1C was reduced from 7.5 to 6.5 percent, along with a 50 percent reduction in medications.

We know that obesity is overwhelming. It’s difficult to lose weight and even harder to reach a normal weight; however, the benefits far outweigh the risks of remaining obese. Lifestyle modifications are a must that should be discussed with your doctor. In addition, there are a range of procedures available to either help jump start the process, to accelerate progress or to help maintain your desired weight.

References: (1) JAMA 2014;311:806-814. (2) JAMA Intern Med 2015;175(8):1412-1413. (3) Am J Public Health 2015;105(9):e54-59. (4) ama-assn.org. (6) cancer.gov/cancertopics/factsheet/risk/obesity. (7) N Engl J Med 2003;348:1625-1638. (8) JAMA Oncol online June 11, 2015. (9) Clin Endocrinol 2015;83(2):147-156. (10) Cancer Prev Res 2015;8(7):1-8. (11) fda.gov. (12) ADA 2015 Abstract 58-OR.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Trump's diet has been brought to the forefront during this election year.

By David Dunaief, M.D.

Donald Trump could learn a thing or two from Bill Clinton. No, we are not talking about politics; we are talking about health. Trump is a public persona, and his diet has been brought to the forefront. As was Clinton’s when he was the United States’ 42nd president. An Aug. 8 New York Times article discussed Trump’s love for fast food and his ironic obsession with cleanliness (1).

Trump’s approach to diet seems to be eerily similar to the standard American diet — with the added detriment of fast food. Though he likes the cleanliness of fast food chains, his arteries may not like the “dirtying” effect of atherosclerosis, or arterial plaques.

Admittedly, I don’t know anything about his family history, including whether or not cardiovascular disease is an issue; nor his blood chemistries, such as cholesterol levels; nor whether or not he has high blood pressure. However, one thing is clear: He is overweight with a significant amount of visceral fat, or belly fat. This type of body fat is considered the most dangerous because it surrounds the internal organs such as the heart (2). This promotes potential cardiovascular disease and diabetes.

For a long time, Bill Clinton also had a love for fast food and the standard American diet. However, this resulted in atherosclerosis, which caused significant blockage of coronary arteries and resulted in coronary artery bypass surgery involving four arteries in 2004. Since then, he has been on a mission to reform his diet. Through the influence of physicians like Drs. Dean Ornish and Caldwell Esselstyn, both advocates of plant-based diets, Clinton has done much better and lost significant weight, as well.

Thus, this is more about the standard American diet, with its high saturated fat, high sugar, refined grains, processed meats and elevated salt versus the nutrient-dense, more likely plant-based, approach with fruits, vegetables and whole grains and their respective effects on cardiovascular disease, atherosclerosis and even mortality.

These type of plant-based diets include the Mediterranean-type diet, the DASH diet, the Ornish diet and the Esselstyn diet.

If we look solely at the differences between saturated fats and unsaturated fats, a recent study involving over 120,000 participants showed that when just 5 percent of pure saturated fats in the diet were replaced with unsaturated fats, this resulted in a significant reduction in all-cause mortality of up to 27 percent over 32 years (3). For more details on this study analysis, see my recent article, “Let the dietary fat wars begin,” which can be found online at www.tbrnewsmedia.com.

I am a firm believer in leading by example. I think it is a powerful way to get patients to follow through with lifestyle changes, especially diet and exercise. That is why the dietary changes I ask my patients to make, I also have been following for years.

Data on cardiovascular disease

Recently, the Centers for Disease Control and Prevention released data about cardiovascular disease that is downright depressing. From 2000 to 2010, the risk of dying from this disease was decreasing by almost 4 percent a year in both men and women (4). However, from 2010 to 2014, this decrease slowed precipitously to 0.23 percent in men and 1.17 percent in women. The reason for this slowdown is that we may have reached a ceiling in the effectiveness of traditional medical interventions. The suggestions are that we concentrate more efforts on lifestyle modifications, specifically diet, physical activity and not smoking.

At the same time, 2011-2012 NHANES data showed a significant increase in obesity and diabetes (5). The bad news is we have not changed our lifestyles enough, especially diet. The good news is that there is a large upside for change and progress!

Reversing heart disease

This research includes both Ornish and Esselstyn. Both physicians have shown it is possible, through a plant-based approach, to have a significant impact on cardiovascular disease, reversing atherosclerosis and preventing a cardiovascular event such as a heart attack.

Esselstyn’s research includes a small study with 24 of his own patients (6). Of these, 18 patients completed the five-year study. These 18 patients had experienced 49 cardiovascular events in the previous eight years. Results show that with a plant-based diet, none of the 18 had a cardiovascular event. Eleven patients chose to have angiographic analysis to determine stenosis, or blockage. None of the 11 progressed; in fact, eight showed regression in atherosclerosis.

Though this was a small study with no control group, the duration, the reversal of atherosclerosis at the study end point and the severity of cardiovascular disease prior to the study make these results intriguing and impressive.

This study was extended to 12 years with similar results and only one additional patient dropping out. Interestingly, those who discontinued the study had a subsequent total of 13 cardiovascular events. One of the key study markers was keeping total cholesterol to lower than 150 mg/dL. The diet emphasized fruits, vegetables, beans, legumes and whole grains.

Then, Esselstyn’s group looked at 198 patients with cardiovascular disease (7). The results were similar to the smaller initial study, with those in the adherent group following a nutrient-dense, plant-based diet experiencing a most astonishing cardiovascular event rate of only 0.6 percent, while the 21 who were nonadherent (the unbeknownst control group, per se) experienced an event rate of 62 percent over 3.7 years.

What about Ornish’s research? Not surprisingly, the results were very similar to Esselstyn’s. In the Ornish study, results showed a reversal in atherosclerosis of 7.9 percent in the treatment group compared to baseline, whereas those in the control arm over the same period showed a 27.7 percent increase in atherosclerosis or plaques in the arteries (8). Also, the control group experienced more than two times as many cardiovascular events as seen in the treatment group. The patients in the treatment group were on a plant-based diet.

There were 48 patients with moderate to severe cardiovascular disease at the beginning of the study, with 28 patients in the treatment group and 20 assigned to the control arm. Of these patients about 75 percent in each group completed the study. The duration of the study was five years. Again, these results are intriguing, and each study reinforces the others.

A clinical example

In my practice, I recently had a 69-year-old white male patient with cardiovascular disease and an extensive family history of the disease, who went to the cardiologist prior to working with me. The initial carotid Doppler (sonogram of the neck arteries) showed a 16 to 50 percent blockage in both carotid arteries. After a year, the carotid Doppler results had been reduced to between 1 and 15 percent blockages in both carotid arteries. The patient’s total cholesterol had dropped to 146 mg/dL, and this result included discontinuing his cholesterol medication, though it was not a statin. Of course, this is anecdotal, but it is consistent with the results mentioned in the studies above.

In conclusion, now you see why Bill Clinton followed the advice of at least two very wise physicians after his quadruple bypass surgery. Lifestyle with a nutrient-dense, plant-based diet not only can prevent cardiovascular disease but may be able to arrest and even reverse plaques in the arteries. Trump would be wise to follow suit and focus on cleanliness of his arteries rather than just cleanliness of the restaurant, as we all would.

References: (1) NYTimes.com. (2) Crit Pathw Cardiol. 2007;6(2):51-59. (3) JAMA Intern Med. 2016;176(8):1134-1145. (4) JAMA Cardiol. online June 29, 2016. (5) cdc.gov/nchs/nhanes. (6) J Fam Pract. 1995;41(6):560-568. (7) J Fam Pract. 2014;63(7):356-364b. (8) JAMA. 1998;280(23):2001-2007.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Consider monitoring blood pressure on both arms. Stock photo

This week, I’d like to discuss some of the nuances of hypertension, or high blood pressure, a contributing risk factor for heart disease. Hypertension affects approximately 33 percent of Americans, according to the latest statistics from the Centers for Disease Control and Prevention, and only 52 percent of these have it controlled (1). What could we possibly learn about blood pressure that we have not heard already? New information is always coming out about this common disease. Studies are teaching us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. Let’s look at the evidence.

Technique

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms, and when one of my longtime patients asked me why, I joked that I need to practice. In truth, it’s because there may be significant benefit from taking readings in both arms.

An analysis of the Framingham Heart Study and Offspring Study showed that when the blood pressure was taken in both arms, when there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease (2).

This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.

So, the next time you go to the doctor’s office, you might want to ask if they would take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Timing

When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (3). This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.

Twenty-four ambulatory blood pressures readings were taken with these patients, which means these were standardized readings. Does this mean that nighttime readings are more important? Not necessarily, but it is an interesting finding. With my patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. However, at least one of the readings should be taken before antihypertensive medications are taken, since these will alter the readings.

Salt impact

There has always been a debate about whether salt really plays a role in high blood pressure and heart disease. The latest installment in this argument is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (4). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

The graphs of sodium reduction mimicked the line graphs for the reductions in deaths from stroke and heart disease. One potential study weakness was that physical activity was not taken into account. However, a strength of this study was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods that we least suspect, such as breads, pastas and cheeses.

Age-related macular degeneration

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, those patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (5). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics, and angiotensin receptor blockers.

However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. In addition, another study actually suggests the opposite — that blood pressure medications may reduce the risk of AMD (6). However, this was a retrospective (backward-looking) study, and it has yet to be published.

This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Fall risk

As we age, falling risk seems to increase. One study shows that blood pressure medications significantly increase fall risk in the elderly (7). Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.

References: (1) CDC.gov/blood pressure. (2) Am J Med. 2014 Mar;127(3):209-215. (3) J Am Soc Hypertens 2014;8:e59. (4) BMJ Open 2014;4:e004549. (5) Ophthalmology online April 30, 2014. (6) ARVO 2013 Annual Meeting: presentation. (7) JAMA Intern Med. 2014;174(4):588-595.

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, visit www.medicalcompassmd.com or consult your personal physician.

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The types, quantity and quality of dietary fat all matter. Stock photo

Dietary fat is one of the most controversial and complicated topics in medicine. Experts have debated this topic for years, ever since we were told that a low-fat diet was important. There are enumerable questions, such as: Is a high-fat diet good for you? What about low-fat diets? If this is not enough, what type of fats should we be consuming?

There are multiple types of fats and multiple fat sources. For instance, there are saturated fats and unsaturated fats, which include monounsaturated and polyunsaturated. There are also trans fats, which are man-made. However, there are several things that we can agree on, like we need fat since the brain is made of at least 60 percent fat (1), and trans fats are downright dangerous. Trans fats are the Frankenstein of fats; anything created in a lab when it comes to fats is not a good thing.

How have we evolved in the fat wars? Originally we were told that a low-fat diet was beneficial for heart disease and weight loss (2). This started in the 1940s but gained traction in the 1960s. By the 1980s, everyone from physicians to the government to food manufacturers was exclaiming about a low-fat diet’s benefits for overall health. But did they go too far trying to make one size fit all? The answer is a resounding YES!!

There are only three macronutrients: fats, carbohydrates and protein. Declaring that one of the three needed to be reduced for everyone did not have the results we wanted or expected. Americans were getting fatter, not thinner, heart disease was not becoming rare, and we were not becoming healthier.

Some fats more equal than others

The biggest debate recently has been over the amount of fats and saturated fats. The most recent 2015-2020 Dietary Guidelines for Americans do not limit the amount of fat, but do limit the amount of saturated fat to less than 10 percent of our diet (3). Does this apply to everyone? Not necessarily. Remember, it is very difficult to apply broad rules to the whole population.

However, the most recent research suggests that foods containing pure saturated fats are not useful, may be detrimental, and at best are neutral. Meanwhile, poly- and monounsaturated fats are potentially beneficial. You will want to read about the most recent study below.

Sources of fat

Pure saturated fats generally are found in animal products, specifically dairy and all meats. The exception is fish, which contains high levels of polyunsaturated fats. Interestingly, most foods that contain predominantly unsaturated fats have saturated fat as well, though the reverse is not typically true. There are also saturated plant oils, like coconut and palm. Processed foods also have saturated fats. Potentially beneficial polyunsaturated fats include fatty fish and some nuts, seeds and soybeans, while potentially beneficial monounsaturated fats are olive oil, avocados, peanut butter, some nuts and seeds (4). Let’s look at the research.

Saturated fat

takes a dive In the ongoing battle over saturated fats, the latest research suggests that it is harmful. In recent well-respected combined observational study (The Nurses’ Health Study and Health Professional Follow-up Study), results show that replacing just 5 percent of saturated fat with poly- or monounsaturated fats results in significant reductions in all-cause mortality, 27 and 13 percent, respectively (5). There were also significant reductions in neurodegenerative diseases, which include macular degeneration, Parkinson’s, Alzheimer’s and multiple sclerosis.

However, when reduced saturated fats were replaced with refined grains, there was no difference in mortality. There were over 126,000 participants with an approximate 30-year duration. Also, the highest quintile of poly- and monounsaturated fat intake compared to lowest showed reductions in mortality that were significant, 19 and 11 percent, respectively. Not surprisingly, trans fat increased the risk of mortality by 13 percent.

The polyunsaturated fats in this study included food such as fatty fish and walnuts, while the monounsaturated fats included foods such as avocado and olive oil. Eating fish had the modest reductions in mortality, 4 percent. The authors suggest replacing saturated fats with healthy poly- and monounsaturated fats that are mostly plant-based, but not with refined grains or trans fat.

Previous study showed neutrality

This was a meta-analysis (a group of 72 heterogeneous trials, some observational and others randomized controlled trials), with results showing that saturated fats were neither harmful nor beneficial, but rather neutral (6).

However, there were significant study weaknesses. The researchers may have used foods that include both saturated fats and unsaturated fats. This is not a pure saturated fat comparison. What did those who had less saturated fat eat instead — refined grains, maybe? Also, the results in the study’s abstract partially contradicted the results in the body of the study. Thus, I would pay a lot more attention to the above study than to this one. Again, though, even the best outcomes for saturated fats in this study did not provide a beneficial effect.

What about butter?

In a meta-analysis (group of nine observational studies), results showed that butter was neither beneficial nor harmful, but rather neutral in effect (7). Then is it okay to eat butter? Not so fast! Remember, the above study showed that saturated fat was potentially harmful, and butter is pure saturated animal fat. Also, there are study weaknesses. It is not clear what participants were eating in place of butter, possibly refined grains, which would obfuscate the potential harms. It was also unclear whether there were poly- and monounsaturated fats in the diet and what effect this might have on making butter look neutral.

Unearthing a saturated fat study

In a randomized controlled trial (Minnesota Coronary Experiment), this one from 1968 to 1973 and not fully analyzed until recently, results showed that polyunsaturated fat from corn oil, compared to a diet with higher saturated fat, reduced cholesterol level while increasing the risk of mortality (8).

The researchers expected the opposite result. Is this a paradox? Fortunately, no! Corn oil is used in processed foods and has a high amount of inflammatory omega-6 fatty acids that may negate the positive results of reducing cholesterol. Plus, the patients were only consuming the corn oil for a short 15-month period, which is unlikely to be long enough to show beneficial effects on mortality.

The bottom line is this: It’s not about low-fat diets! Saturated fats have not shown any benefits, and could be potentially harmful, but at best, they are neutral. However, foods that contain high amounts of poly- or monounsaturated fats that are mostly plant-based have shown significant benefit in reducing the risk of death and neurodegenerative diseases.

However, there are several caveats. Not all unsaturated fats are beneficial. For instance, some like corn oil may contain too many omega-6 fatty acids, which could contribute to inflammation. Also, replacing saturated fats with carbohydrates, especially refined grains, does not improve health. I told you fats are not easy to understand. It can be helpful to change our perception of fats: They are not “good and bad.” Instead, think of them as “useful and useless.” For our health, we should be focused on the “useful.”

References: (1) Acta Neurol Taiwan. 2009;18(4):231-241. (2) J Hist Med Allied Sci 2008;63(2):139-177. (3) health.gov/dietaryguidelines/2015. (4) https://www.heart.org. (5) JAMA Intern Med. 2016;176(8):1134-1145. (6) Ann Intern Med. 2014;160(6):398-406. (7) PLoS ONE 11(6):e0158118. (8) BMJ 2016;353:i1246.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Exercise is important in reducing the risk of fractures. Stock photo

By David Dunaief, MD

Osteoporosis is a complex disease. For one thing, it progresses with no symptoms, until the more severe stage of fractures that cause potential disability and increase mortality. For another, the only symptoms are from the treatment with medications, better known as side effects. Third, lifestyle modifications and supplements, while important, require adherence to a regimen.

I am not a big advocate of medication, as I am sure you have gathered from my previous articles; however, medication does have its place. There are studies that show benefit from the two main classes for osteoporosis, bisphosphonates such as alendronate (Fosamax, though it is now generic) and the newer class that involves monoclonal antibodies such as denosumab (Prolia). And, of course, I am a big advocate of lifestyle modifications including diet, exercise, smoking cessation and even some supplements. The side effects of these modifications are better health outcomes for chronic diseases and disorders in general. What I can’t advocate for, as a physician sworn to help people, is the new emerging cohort that I refer to as the “do-nothing group.”

Recently, a New York Times article on June 1, 2016, entitled, “Fearing Drugs’ Rare Side Effects, Millions Take Their Chances With Osteoporosis,” reported that prescriptions for medications to treat the disease have fallen by more than 50 percent from 2008 to 2012 because of the fear of the side effect profile that include rare instances of atypical fractures and jawbone necrosis (1).

In the article, one doctor mentions that patients prefer diet and exercise, but that it does not work. Well, he may be partially correct. Diet and exercise may not work if they’re not implemented. However, if people actually make lifestyle modifications, there could be substantial benefit. Just to give up on the medications for osteoporosis or to refuse to take them is not going to improve your chances or reduce your risk of getting fractures in the spine, hip, wrist or other locations. In other words, the “do-nothing” approach won’t help and may significantly increase your risk of fracture and other complications, such as death.

At the top of the list of risk factors for osteoporosis is nontraumatic fractures — in other words, breaking of bone with low-impact events. In this case, once you have had a fracture, the probability of having a recurrent or subsequent fracture increases more than three times in the first year, according to a recent Icelandic study (2). Lest you think that you are in the clear after a year since your first fracture: After 10 years, the risk of subsequent fracture still remains high, with a twofold increased risk.

Osteoporosis involves bone loss. We typically measure this through the bone mineral density (BMD) biomarker using a DXA scan. However, another component is bone quality. Sarcopenia, or loss of lean muscle mass, may play a role in bone quality. There are vitamins, such as vitamin K2, that can have beneficial effects on bone based on bone quality as well. No, this is not the same as the more well-known vitamin K1 used in clotting, which may also have a smaller benefit in preserving bone.

Let’s look at the evidence.

Avoiding sacropenia

Sarcopenia is a fancy word for a depressing phenomenon that occurs as we age and become more and more sedentary; it is the loss of lean skeletal muscle mass at the rate of 3 to 8 percent each consecutive decade after 30 and also loss of strength (3). It may have significant effects on about one-third of those over age 60 and half of those over 80. Unless, of course, you are physically active on a regular basis. In the Study for Osteoporotic Fractures in Men, results show that sarcopenia plus osteoporosis, taken together, increases the risk of fracture more than three times in older men (4).

The researchers assessed muscle wasting by using the European Working Group on Sarcopenia in Older Patients (EWGSOP), which takes into account weakness (grip strength <20 kg for men), slowness (walking=0.8 m/s) and low lean muscle mass (< 20 percent). This involved over 5,000 men with a mean age of about 74. The group with sarcopenia had significantly lower grip strength and was less physically active. In another study, those who were healthy 65-year-old adults who had sarcopenia or low lean muscle mass were at a greater than two times risk of experiencing a low-trauma fracture within three years (5). This was according to the EWGSOP1 cutoff criteria for sarcopenia.

Preventing sarcopenia

Well, beyond the obvious of physical activity and formal exercise, there is a medication that has potentially shown positive results. This is the bisphosphonate alendronate (Fosamax). In a study, results showed that alendronate increased muscle mass significantly over a one-year period (6). In the appendicular (locomotive) skeletal muscle, there was a 2.5 times increase in muscle mass, while in lower limb muscle mass there was a greater than four times increase. This was a retrospective (backward-looking), case-control study involving about 400 participants. While these results are encouraging, we need a prospective (forward-looking), randomized controlled trial. For those who don’t want to or can’t for some reason exercise, then medication may help with muscle mass.

Exercise! Exercise! Exercise!

In a meta-analysis (a group of 10 trials), results showed there was a significant 51 percent reduction in the risk of overall fracture in postmenopausal women who exercised (7). This study involve over 1,400 participants. Does exercise intensity matter? Fortunately, the answer is no. If you like jogging or running, that’s great, but walking was also beneficial. This is important, since you want to do the type of activity that is more enjoyable to you, especially since the benefit of exercise dissipates when you stop doing it regularly (8).

The importance of K2

In a recent study, vitamin K2 was shown to reduce the risk of hip fracture by 60 percent, vertebral fracture by 77 percent and nonvertebral fractures by a whopping 81 percent (9). According to the authors, this benefit may be derived from bone strength (BMC, or bone mineral content) rather than from bone mineral density (BMD). There were 325 postmenopausal women in this study. It was a randomized controlled trial with one group receiving vitamin K2 (MK-4, menatetrenone) supplementation of 45 mg/day and the other a placebo group.

Don’t forget fruits and vegetables

In the Singapore Chinese Health Study, a prospective population-based study, results showed that there was a 34 percent reduction in the risk of hip fracture in the highest quintile of vegetable-fruit-soy (VFS) intake, compared to the lowest quintile (10). This study involved over 63,000 men, premenopausal and postmenopausal women with an age range from 45 to 74 years old. The results showed a dose-dependent curve, meaning the more VFS, the higher the reduction in hip fracture risk. Interestingly, there was no difference in risk of fracture when meat in the form of meat dim-sum was used instead of plant-based protein. The researchers concluded that an Asian plant-based diet may help reduce the risk of hip fracture. I’m not saying to take medications for osteoporosis, but you need to do something — either medications, lifestyle modifications, supplements or all three — especially if you have a history of low-trauma fractures, because your risks of disability, complications and death increase significantly with subsequent fractures. But, do not be part of the growing “do-nothing” group.

References:

(1) J Bone Miner Res. 2015;30(12):2179-2187. (2) World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases 2016. Abstract 0C35. (3) Curr Opin Clin Nutr Metab Care. 2009; 12(1):86–90. (4) American Society of Bone and Mineral Research 2013. Abstract 1026. (5) Age Ageing.2010;39:412-423. (6) Osteoporos Sarcopenia. 2015;1(1):53-58. (7) Osteoporos Int. 2013;24(7):1937. (8) Ann Intern Med. 1988;108(6):824. (9) Osteoporos Int. 2007;18(7):963-972. (10) J Nutr. 2014;144(4):511-518.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Iron is important for exercise motivation and may play a role in peak mental functioning. Stock photo

I believe the most salient teaching point in medical school and beyond was when a professor explained, as it relates to the patient diagnosis, when you hear hooves think horses not zebras. What this means is think of the more common or more likely diseases or disorders in a differential diagnosis rather than the more esoteric or rare diseases. And when a patient presents with fatigue, one of the more common reasons is iron deficiency.

Major causes of low iron are anemia of chronic disease, iron deficiency anemia, sideroblastic anemia and thalassemia. Of these, iron deficiency anemia is the most common. However, there is a much less known, but not uncommon, form of low iron. This is called iron deficiency without anemia. Unlike iron deficiency anemia, the straightforward CBC (complete blood count) that is usually drawn cannot detect this occurrence since the typical indicators, hemoglobin and hematocrit, are not yet affected.

So how do we detect iron deficiency without anemia? Not to despair, since there is a blood test done by major labs called ferritin. What is ferritin? Ferritin is a protein that is involved in iron storage. When ferritin is less than 10 to 15 ng/ml, the diagnosis of iron deficiency is most likely indicated. Even healthy people with ferritin slightly higher than this level may also have iron deficiency (1). The normal range of ferritin is 40-200 ng/ml.

At this point, you should be asking who does low ferritin affect and what are the symptoms? Women and athletes are affected primarily, and low ferritin levels may cause symptoms of fatigue. It is also seen with some chronic diseases such as restless leg syndrome (RLS) and attention deficit hyperactivity disorder (ADHD) in children.

Effect on women

In a prospective (forward-looking) study done in 1993 looking at primary care practices, it was determined that 75 percent of patients complaining of fatigue were women (2). Interestingly, less than 10 percent of these women had abnormal lab results when routine labs were drawn, most probably without a ferritin level. Many of them had experienced these symptoms for at least three months.

There was a randomized controlled trial (RCT), the gold standard of studies, that showed women who were suffering from fatigue and low or low-normal ferritin levels (less than 50 ng/ml), but who did not have anemia, benefited from iron supplementation (3). When comparing women with these ferritin levels, many of those who were given 80 mg of oral prolonged release ferrous (iron) sulfate supplements daily saw a significant improvement in their fatigue symptoms when compared to those women who were not given iron. Almost half the women taking iron supplements had a significant improvement in fatigue symptoms. The results were seen in a very short 12-week period. This is nothing to sneeze at, since fatigue is one of main reasons people go to the doctor. Also, although this was a small study, there were 198 women involved, ranging from 18 to 53 years old.

There are caveats to these study results. There was no improvement in depression or anxiety symptoms, nor in overall quality of life. Even though it was blinded, stool changes occur when a patient takes iron. Therefore, the women taking supplements may have known. Nonetheless, the study results imply that physicians should check ferritin level, not only a CBC, when a premenopausal woman complains of fatigue. Note that all of the women in the study were premenopausal. This is important to delineate, since postmenopausal women are at much higher risk of iron overload, rather than deficiency. They are no longer menstruating and therefore do not rid themselves of significant amounts of iron.

Athletes

According to an article in The American Journal of Lifestyle Medicine, athletes’ endurance may be affected by iron deficiency without anemia (4). Low ferritin levels are implicated, as in the previous study. Iron is important for exercise motivation and may play a role in peak mental functioning, as reported in “Iron: Nutritional and Physiological Significance.” In animal studies, iron deficiency without anemia is associated with reduction in endurance because of a decrease in oxygen-based enzymatic activity within the cells.

However, this has not been shown definitively in human athletes and remains an interesting, but yet to be proven, hypothesis. Interestingly, female endurance athletes are more likely to be affected by iron deficiency without anemia, which occurs in about 25 percent of this population, according to studies (5). Low ferritin is not seen as much in male athletes. This difference in gender may be due to the fact that women not only menstruate, losing iron on a regular basis, but also their intake of dietary iron seems to be lower (6).

However, male athletes are not immune. At the end of the season for high school runners, 17 percent had iron deficiency without anemia (7). Do not take iron supplements without knowing your levels of hemoglobin and ferritin and without consulting a doctor. Studies are mixed on the benefits of iron supplementation without anemia for athletes.

Impact on restless leg syndrome

Iron deficiency with a ferritin level lower than 50 ng/ml affects approximately 20 percent of patients who suffer from restless leg syndrome (8). Restless leg syndrome, classified as a neurologic movement disorder, causes patients to feel like they need to move their legs, most commonly about a half-hour after going to bed. In a very small study, patients with restless leg syndrome who had ferritin levels lower than 45 ng/ml saw significant improvement in symptoms within eight days with iron supplementation (9).

Before you get too excited, the caveat is that 75 percent of restless leg patients have high ferritin levels. It is impressive in terms of being an easy fix for those who have low ferritin levels. And, it may be that high ferritin levels in RLS has the same symptoms as low ferritin for this is the case when it comes to iodine levels in hypothyroid patients. Iron is a trace mineral, meaning we only need small amounts to maintain proper levels.

Ferritin levels — both high and low — may play a role in a number of diseases and symptoms. If you are suffering from fatigue, a CBC test may not be enough to detect iron deficiency. You may want to suggest checking your ferritin level. Though iron supplementation may help those with symptomatic iron deficiency without anemia, it is very important not to take iron supplements without the direct supervision of your physician.

References: (1) Br J Haematol. 1993;85(4):787-798. (2) BMJ 1993;307:103. (3) CMAJ. 2012;184(11):1247-1254. (4) Am J Lifestyle Med. 2012;6(4):319-327. (5) J Am Diet Assoc. 2005;105:975–978. (6) J Pediatr. 1989;114:657–663. (7) J Adolesc Health Care. 1987;8:322–326. (8) Am Fam Physician. 2000;62(4):736. (9) Sleep Med. 2012;13(6):732-735. 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, visit www.medicalcompassmd.com or consult your personal physician.

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Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. Stock photo

By David Dunaief, MD

Most of us have experienced a difficult night’s sleep. However, those with obstructive sleep apnea (OSA) may experience a lack of restful sleep much more frequently.

OSA is an abnormal pause in breathing while sleeping that occurs at least five times an hour. There are a surprising number of people in the United States who have this disorder. The prevalence may be as high as 20 percent of the population, and 26 percent are at high risk for the disorder (1). There are three levels of OSA: mild, moderate and severe.

The risk factors for OSA are numerous and include chronic nasal congestion, large neck circumference, being overweight or obese, alcohol use, smoking and a family history.

Not surprisingly, about two-thirds of OSA patients are overweight or obese. Smoking increases risk threefold, while nasal congestion increases risk twofold (2). Fortunately, as you can see from this list, many of the risk factors are modifiable.

The symptoms of OSA are significant: daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration and morning headaches. These symptoms, while serious, are not the worst problems. OSA is also associated with a list of serious complications, such as cardiovascular disease, high blood pressure and cancer.

There are several treatments for OSA. Among them are continuous positive airway pressure — known as CPAP — devices; lifestyle modifications, including diet, exercise, smoking cessation and reduced alcohol intake; oral appliances; and some medications.

Cardiovascular disease

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

Not to leave out men, another observational study showed similar risks of cardiovascular disease with sleep apnea and benefits of CPAP treatment (4). There were more than 1,500 men in this study with a follow-up of 10 years. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in stemming these occurrences. In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA 38 and 125 percent, respectively (5). But, just like in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

Though all three studies were observational, it seems that OSA affects both genders and all ages when it comes to increased risk of cardiovascular disease and death, and CPAP may be effective in reducing these risks.

Cancer association

In sleep apnea patients under 65 years old, a study showed an increased risk of cancer (6). The authors believe that intermittent low levels of oxygen, which are caused by the many frequent short bouts of breathing cessation during sleep, may be responsible for the development of tumors and their subsequent growth.

The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. So, for those patients with more than 12 percent low-oxygen levels at night, there is a twofold increased risk of cancer development, when compared to those with less than 1.2 percent low-oxygen levels.

Sexual function

It appears that erectile dysfunction may also be associated with OSA. CPAP may decrease the incidence of ED in these men. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspect of this study was that, at baseline, the participants were overweight — not obese — on average and were young, at 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

Dietary effect

Although CPAP can be quite effective, as shown in some of the studies above, it may not be well tolerated by everyone. In some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or may be used in combination with CPAP.

In a small study, a low-energy diet showed positive results in potentially treating OSA. It makes sense, since weight loss is important. But even more impressively, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year. Patients studied were those who suffered from moderate-to-severe levels of sleep apnea. Low-energy diet implies a low-calorie approach. A diet that is plant-based and nutrient-rich would fall into this category. One of my patients who suffered from innumerable problems was able to discontinue his CPAP machine after following this type of diet.

The bottom line is that if you think you or someone else is suffering from sleep apnea, it is very important to go to a sleep lab to be evaluated, and then go to your doctor for a follow-up. Don’t suffer from sleep apnea and, more importantly, don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are effective treatments for this disorder, including diet and/or CPAP.

References: (1) WMJ. 2009;108(5):246. (2) JAMA. 2004;291(16):2013. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) Am J Respir Crit Care Med. 2012 Nov. 15. (7) APSS annual meeting: abstract No. 0574. (8) BMJ. 2011;342:d3017.

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, visit www.medicalcompassmd.com or consult your personal physician.

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