Osteoarthritis is widespread. The more common joints affected are the knees, hips and hands. There are three types of treatment for this disease: surgery, involving joint replacements of the hips or knees; medications; and nonpharmacologic approaches. The most commonly used first-line medications are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, medications mostly treat the symptoms of pain and inflammation.

However, the primary objectives in treating osteoarthritis should also include improving quality of life, slowing progression of the disease process and reducing its disabling effects (1).

Dairy and milk

When we think of dairy, specifically milk, there are two distinct camps: one believes in the benefits, and the other thinks it may contribute to disease. In this case they both may be at least partly correct. In the Osteoarthritis Initiative study, an observational study of over 2,100 patients, results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis (2).

The researchers looked specifically at joint space narrowing that occurs in those with affected knee joints. Radiographic imaging changes were used at baseline and then to follow the patients for up to 12 to 48 months for changes. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space.

Was it a dose-dependent response? Not necessarily. Specifically, those who drank less than three glasses/week and those who drank four to six glasses/week both saw slower progression of joint space narrowing of 0.09 mm. Seven to 10 glasses/week resulted in a 0.12 mm preservation. However, those who drank more than 10 glasses/week saw less beneficial effect, 0.06 mm preservation compared to those who did not drink milk. Interestingly, there was no benefit seen in men or with the consumption of cheese or yogurt.

However, there are significant flaws with this study. First, patients were only asked about their dietary intake of milk at baseline; therefore their consumption could have changed during the study. Second, there was a recall bias; patients were asked to recall their weekly milk consumption for the previous 12 months before the study began. I don’t know about you, but I can’t recall my intake of specific foods for the last week, let alone for the past year. Third, there could have been confounding factors, such as orange juice consumption.

Oddly, this was not a dose-response curve, since the most milk consumption had less beneficial effect than lower amounts. Also, why were these effects only seen in women? Finally, researchers could not explain why low-fat or nonfat milk had this potential benefit, but cheese was detrimental and yogurt did not show benefit. We are left with more questions than answers.

Would I recommend consuming low-fat or nonfat milk? Not necessarily, but I may not dissuade osteoarthritis patients from drinking it. There are very few approaches that slow the progression of joint space narrowing.

Vitamin D

Over the last five years or so, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a recent randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief nor any disease-modifying effects (3). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

Glucosamine

There is raging debate about whether glucosamine is an effective treatment for osteoarthritis. In the latest installment, there was an RCT, the results of which showed that glucosamine hydrochloride was not effective in treating osteoarthritis (4). In the trial, 201 patients with either mild or moderate knee pain drank diet lemonade with or without 1500 mg of glucosamine hydrochloride.

There was no difference in cartilage changes in the knee nor in pain relief in those in the placebo or treatment groups over a six-month duration. Bone marrow lesions also did not improve with the glucosamine group. The researchers used 3T MRI scans (an advanced radiologic imaging technique) to follow the patients’ disease progression. This does not mean that glucosamine does not work for some patients. Different formulations, such as glucosamine sulfate, were not used in this study.

Weight

This could not be an article on osteoarthritis if I did not talk about weight. Do you remember analogies from the SATs? Well here is one for you: Weight loss, weight loss, weight loss is to osteoarthritis as location, location, location is to real estate. In a recent study involving 112 obese patients, there was not only a reduction of knee symptoms in those who lost weight, but there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5). On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet

In a recent study, diet AND exercise trumped the effects of diet OR exercise alone (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a well-designed, randomized controlled single-blinded study with a duration of 18 months.

Researchers used a biomarker — IL6 — to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times per week.

Therefore, concentrate on lifestyle modifications if you want to see potentially disease-modifying effects. These include both exercise and diet. In terms of low-fat or nonfat milk, while the study had numerous flaws, if you drink milk, you might continue for the sake of osteoarthritis, but stay on the low end of consumption. And remember, the best potential effects shown are with weight loss and with a vegetable-rich diet.

References:

(1) uptodate.com. (2) Arthritis Care Res online. 2014 April 6. (3) JAMA. 2013;309:155-162. (4) Arthritis Rheum online. 2014 March 10. (5) Ann Rheum Dis online. 2014 Feb. 11. (6) JAMA. 2013;310:1263-1273.

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 www.medicalcompassmd.com or consult your personal physician.

September marks the beginning of the academic calendar and noticeably shorter daylight hours. The pace of life tends to become more hectic. Although some stress is valuable to help motivate us and keep our minds sharp, high levels of constant stress can have detrimental effects on the body.

It is very likely that there is a mind-body connection when it comes to stress. In other words, it may start in the mind, but it can lead to acute or chronic disease promotion. Stress can also play a role with your emotions, causing irritability and outbursts of anger and possibly leading to depression and anxiety. Stress symptoms are hard to distinguish from other disorders but can include stiff neck, headaches, stomach upset and difficulty sleeping. Stress may also be associated with cardiovascular disease, with an increased susceptibility to infection from viruses causing the common cold and with cognitive decline and Alzheimer’s (1).

A stress steroid hormone called cortisol is released from the adrenal glands and can have beneficial effects in small bursts. We need cortisol in order to survive. Some of cortisol’s functions include raising glucose (sugar) levels when they are low and helping reduce inflammation and stress levels (2). However, when cortisol gets out of hand, higher chronic levels may cause inflammation, leading to disorders such as cardiovascular disease, as recent research suggests. Let’s look at the evidence.

Inflammation 

Inflammation may be a significant contributor to more than 80 percent of chronic diseases, so it should be no surprise that it is an important factor with stress. In a recent meta-analysis (a group of two observational studies), high levels of C-reactive protein (CRP), a biomarker for inflammation, were associated with increased psychological stress (3).

What is the importance of CRP? It may be related to heart disease and heart attacks. This study involved over 73,000 adults who had their CRP levels tested. The research went further to suggest that increased levels of CRP may result in more stress and also depression. With CRP higher than 3.0 there was a greater than twofold increase in depression risk. The researchers suggest that CRP may heighten stress and depression risk by increasing levels of different proinflammatory cytokines, inflammatory communicators among cells (4).

In one recent study, results suggested that stress may influence and increase the number of hematopoietic stem cells (those that develop all forms of blood cells), resulting specifically in an increase in inflammatory white blood cells (5). The researchers suggest that this may lead to these white blood cells accumulating in atherosclerotic plaques in the arteries, which ultimately could potentially increase the risk of heart attacks and strokes. Chronic stress overactivates the sympathetic nervous system — our “fight or flight” response — which may alter the bone marrow where the stem cells are found. This research is preliminary and needs well-controlled trials to confirm these results.

Infection

Stress may increase the risk of colds and infection. Cortisol over the short term is important to help suppress the symptoms of colds, such as sneezing, cough and fever. These are visible signs of the immune system’s infection-fighting response. However, the body may become resistant to the effects of cortisol, similar to how a type 2 diabetes patient becomes resistant to insulin. In one study of 296 healthy individuals, participants who had stressful events and were then exposed to viruses had a higher probability of catching a cold. It turns out that these individuals also had resistance to the effects of cortisol. This is important because those who were resistant to cortisol had more cold symptoms and more proinflammatory cytokines (6).

Diabetes and heart disease

When we measure cortisol levels, we tend to test the saliva or the blood. However, these laboratory findings only give one point in time. Thus, when trying to determine if raised cortisol may increase cardiovascular risk, the results are mixed. However, in a recent study, measuring cortisol levels from scalp hair was far more effective (7). The reason for this is that scalp hair grows slowly, and therefore it may contain three months’ worth of cortisol levels. The study showed that those in the highest quartile of cortisol levels were at a three times increased risk of developing diabetes and/or heart disease compared to those in the lowest quartile. This study involved older patients between the ages of 65 and 85.

Lifestyle changes can reduce effects of stress

Lifestyle plays an important role in stress at the cellular level, specifically at the level of the telomere, which determines cell survival. The telomeres are to cells as the plastic tips are to shoelaces; they prevent them from falling apart. The longer the telomere, the slower the cell ages and the longer it survives. In a recent study, those women who followed a healthy lifestyle — one standard deviation over the average lifestyle — were able to withstand life stressors better since they had longer telomeres (8).

This healthy lifestyle included regular exercise, a healthy diet and a sufficient amount of sleep. On the other hand, the researchers indicated that those who had poor lifestyle habits lost substantially more telomere length than the healthy lifestyle group. The study followed women 50 to 65 years old over a one-year period.

In another study, chronic stress and poor diet (high sugar and high fat) together increased metabolic risks, such as insulin resistance, oxidative stress and central obesity, more than a low-stress group eating a similar diet (9). The high-stress group members were caregivers, specifically those caring for a spouse or parent with dementia. Thus, it is especially important to eat a healthy diet when under stress.

Interestingly, in terms of sleep, the Evolution of Pathways to Insomnia Cohort study shows that those who deal with stressful events directly are more likely to have good sleep quality. Using medication, alcohol or, most surprisingly, distractors to deal with stress all resulted in insomnia after being followed for one year (10). Cognitive intrusions or repeat thoughts about the stressor also resulted in insomnia.

Psychologists and other health care providers sometimes suggest distraction from a stressful event, such as television watching or other activities, according to the researchers. However, this study suggests that this may not help avert chronic insomnia induced by a stressful event. The most important message from this study is that how a person reacts to and deals with stressors may determine whether they suffer from insomnia.

Constant stress is something that needs to be recognized. If it’s not addressed, it can lead to suppressed immune response or increased levels of inflammation. CRP is an example of an inflammatory biomarker that may actually increase stress. In order to address chronic stress and lower CRP, it is important to adopt a healthy lifestyle that includes sleep, exercise and diet modifications. Good lifestyle habits may also be protective against the effects of stress on cell aging.

References:

(1) Curr Top Behav Neurosci. 2014 Aug. 29. (2) Am J Physiol. 1991;260(6 Part 1):E927-E932. (3) JAMA Psychiatry. 2013;70:176-184. (4) Chest. 2000;118:503-508. (5) Nat Med. 2014;20:754-758. (6) Proc Natl Acad Sci U S A. 2012;109:5995-5999. (7) J Clin Endocrinol Metab. 2013;98:2078-2083. (8) Mol Psychiatry Online. 2014 July 29. (9) Psychoneuroendocrinol Online. 2014 April 12. (10) Sleep. 2014;37:1199-1208.

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 www.medicalcompassmd.com or consult your personal physician.

A TIA (transient ischemic attack) is sometimes referred to as a “mini-stroke.” This is a disservice since it makes a TIA sound like something that should be taken lightly. Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot across the bow that needs to be taken very seriously on its own merit. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common? It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (1). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. I have helped manage patients with symptoms as understated as the onset of double vision. Other symptoms may include facial or limb weakness on one side, slurred speech or problems comprehending others, dizziness or difficulty balancing or blindness in one or both eyes (2). TIA incidence increases with age (3).

What is a TIA? The definition has changed over time from one purely based on time (less than one hour), to differentiate it from a stroke, to one that is tissue-based. It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia (low blood flow in the back of the eye) without evidence of acute infarction (tissue death) (4). In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, creating difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Why take a TIA seriously if its debilitating effects are temporary? Though they are temporary, TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death.

Despite the seriousness of TIAs, patients or caregivers often delay receiving treatment.

Stroke

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (5). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (6). Even worse, over the long term, the probability that a patient will experience a stroke reaches approximately 30 percent, one in three, after five years (7).

To go even further, there was a study that looked at the immediacy of treatment. The EXPRESS study, a population-based study that considered the effect of urgent treatment of TIA and minor stroke on recurrent stroke, evaluated 1,287 patients, comparing their initial treatment times after experiencing a TIA or minor stroke and their subsequent outcomes (8).

The Phase 1 cohort was assessed within a median of three days of symptoms and received a first prescription within 20 days. In Phase 2, median delays for assessment and first prescription were less than one day. All patients were followed for two years after treatment. Phase 2 patients had significantly improved outcomes over the Phase 1 patients. Ninety-day stroke risk was reduced from 10 percent to 2 percent, an 80 percent improvement.

The study’s authors advocate for the creation of TIA clinics that are equipped to diagnose and treat TIA patients to increase the likelihood of early evaluation and treatment and decrease the likelihood of a stroke within 90 days. The moral of the story is thus, treat a TIA as a stroke should be treated, the faster the diagnosis and treatment, the lower the likelihood of sequalae or complications.

Predicting the risk of stroke complications

Both DWI (diffusion weighted imaging) and ABCD2 are potentially valuable predictors of stroke after TIA. The ABCD2 is a clinical tool used by physicians. ABCD2 stands for Age, Blood pressure, Clinical features and Diabetes, and it uses a scoring system from 0 to 7 to predict the risk of a stroke within the first two days of a TIA (9).

Heart attack

In one epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (10). These were patients without known heart disease. Interestingly, the risk of heart attacks was much higher in those over 60 years of age and continued for years after the event. Just because you may not have had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack. Even patients taking statins to lower cholesterol were at higher risk of heart attack after a TIA.

Mortality

If stroke and heart attack were not enough, TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years, and by 20 percent after nine years, especially in those over age 65, according to a study published in Stroke online on Nov. 10, 2011. The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort (particular group of patients) study that involved over 5,000 participants, TIA was associated with an almost 2.5 times increased risk of depressive disorder (11). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (12). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include a Mediterranean and DASH diet combination. Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

In researching information for this article, I realized that there are not many separate studies for TIA; they are usually clumped with stroke studies. This underscores the seriousness of this malady. If you or someone you know has TIA symptoms, the patient needs to see a neurologist and a primary care physician and/or a cardiologist immediately for assessment and treatment to reduce risk of stroke and other long-term effects.

References:

(1) Stroke. Apr 2005;36(4):720-723; Neurology. May 13 2003;60(9):1429-1434. (2) mayoclinic.org. (3) Stroke. Apr 2005;36(4):720-723. (4) N Engl J Med. Nov 21 2002;347(21):1713-1716. (5) Neurology. 2011 Sept 27; 77:1222. (6) Lancet Neurol. Dec 2007;6(12):1063-1072. (7) Albers et al., 1999. (8) Stroke. 2008;39:2400-2401. (9) Lancet. 2007;9558;398:283-292. (10) Stroke. 2011; 42:935-940. (11) Stroke. 2011 Jul;42(7):1857-1861. (12) JAMA. 2005 Mar 23;293(12):1435.

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 www.medicalcompassmd.com or consult your personal physician.

I’ve noticed quite a few runners and bikers in the neighborhood this summer. I’ve also noticed an increase in the number of folks lined up at the local ice cream shop and wondered at the intersection of these two groups — the exercisers and the summer eaters. Conventional wisdom tells us that if we’re going to eat calorically dense foods, we need to be prepared to work off the potential extra pounds.

Before I go on, let’s take a little quiz. A little knowledge goes a long way in feeling good about your plans to exercise.

Unfortunately, the answer to question one is “d.” Exercise without dietary changes may not actually help many people to lose weight, no matter what the intensity or the duration (1). If it does help, it may only moderately reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance. Therefore, it may be more important to think about what you are eating rather than succumb to the rationalization that you can eat with abandon and work it off later.

Don’t give up on exercise just yet, though. There is very good news: the answer to question two is that exercise has beneficial effects on all the choices plus many others, including diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia, and depression. Let’s look at the evidence.

Weight loss attenuated

The well-known weight-loss paradigm in medicine is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, the results of one study say otherwise. They show that in premenopausal women, there was neither weight nor fat loss from exercise (2). This was a preliminary study that involved 81 women over a short duration, twelve weeks. All the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of, predominantly, fat. There was significant variability seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max —maximum oxygen consumption during exercise — or, in other words, a moderately intense pace.

The good news is that the women were in better aerobic shape by the end of the study and that women who lost weight at the four-week mark were more likely to continue to do so by the end of the study. Though this is an interesting finding about variable effects on weight with exercise, this was also a preliminary study, so there needs to be a larger and longer duration study to confirm these results.

Other studies have shown modest weight loss. For instance, in a meta-analysis of 14 randomized controlled trials — the gold standard of studies — results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Weight maintenance

However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Chronic kidney disease

Chronic kidney disease affects about 1 in 10 people in the United States, according to the Centers for Disease Control and Prevention (7). The U.S. Preventive Services Task Force has indicated that there is insufficient evidence to treat asymptomatic CKD. In fact, the American College of Physicians has said that asymptomatic CKD, which includes stages 3a and 3b, or moderate disease levels, should not be screened for, since the risks outweigh the benefits and lead to false positive tests and unnecessary treatments (8).

However, in a recent trial, the results show that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3-5 (9). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had such an impressive impact, results were based on a dose-response curve. In other words, the more frequently patients walked in the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

Rheumatoid arthritis

Unfortunately, more than three quarters of patients with rheumatoid arthritis are affected with varying degrees of hand dysfunction. Well, it turns out that a randomized controlled trial that included supervised (physiotherapist or occupational therapist) exercise for six sessions, and exercise at home showed more than twice the improvement in hand function than those in the usual care group, over a 12-month period (10). There were no changes in drug therapies or pain.

Therefore, while it is important to enjoy the remaining weeks of summer, which officially ends September 21st, it is food choices that will have the greatest impact on our weight and body composition. Exercise will not be the solution for most of us to overcome weight gain. However, exercise is extremely beneficial for preventing progression of chronic disorders, such as CKD. Improved functioning of the hand with exercise in rheumatoid arthritis patients reduces disability.

So, by all means, exercise, but also focus on more nutrient-dense foods. At the least, strike a balance, rather than eating purely calorically dense foods. They are unlikely to be rationalized with exercise.

References:

(1) update.com. (2) J Strength Cond Res., Online, Oct. 28, 2014. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Ann Intern Med., online, Oct. 21, 2013. (9) Clin J Am Soc Nephrol. 2014 July 9(7):1183-9. (10) Lancet., online, Oct. 9, 2014.

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 www.medicalcompassmd.com or consult your personal physician.

I think most of us can agree that we want to age as gracefully as possible. But, what does this mean? While we may want to avoid physical ailments, such as achy joints and musculoskeletal pain, cognitive decline seems to be one of the scarier prospects as we age. The one organ in our body that we can’t yet transplant is the brain, so we really need to keep it in the best shape possible. We will all experience some form of age-related cognitive decline. But what about more significant changes in brain function?

The prevalence of mild cognitive impairment is hard to quantify, but roughly 16 to 22 percent of us will experience it (1). The reason for the range is that it is difficult to define but is thought of as a disorder that is between normal cognition and dementia. However, it is not a normal stage of aging. Mild cognitive impairment may lead to dementia, which is defined as affecting the memory and also at least one other part of the brain, such as executive functioning (2). The most common form is Alzheimer’s disease.

Who is at highest risk for decline from mild cognitive impairment and dementia? It turns out that this is a potential question of gender. Of those with mild cognitive impairment, women tend to worsen at an almost two times faster rate than men (3). However, researchers were baffled as to why.

There are preventions and treatments that may alter these different disorders that affect our mental functioning.

There may also be tests to determine whether you are at increased risk for dementia. These range from a short mental exam in the physician’s office to a saliva test that measures cortisol levels, the stress hormone. Higher levels of cortisol at night than normal were associated with significantly less brain volume and reductions in cognitive function in participants who did not have signs of impairment yet (4).

As “location, location, location” is important to real estate, it seems that lifestyle modifications including exercise, diet and overall brain fitness may be important to cognitive functioning.

Where do drugs fit in terms of treating dementia? The main class of drugs, cholinesterase inhibitors, seems to disappoint and also appears to have significant side effects.

Let’s look at the evidence.

Side effects of medication

Unfortunately, we do not have medication that is a silver bullet to successful outcomes in dementia. The mainstay medications are among a class referred to as anti-cholinesterase inhibitors, drugs that have a mild effect on dementia. These drugs include Aricept (donepezil), Exelon (rivastigmine) and Razadyne (galantamine). In a recent study, results showed that anti-cholinesterase inhibitors caused significant weight loss (5). Compared to those not on anti-cholinesterase inhibitors, there was a 23 percent increased risk of at least 10 pounds or more in unintentional weight loss over 12 months. There were more than 6,000 patients who were 65 years and older involved in the VA health systems retrospective study. This means that approximately 1 in 21 patients treated with these drugs may experience harmful weight loss over one year. Talk to your doctor about the risks and benefits of this drug class.

Exercise, exercise, exercise

Why? There are three recent studies showing exercise’s beneficial impact on cognitive functioning. Exercise may play a role in not just prevention but also in treatment.

Two of the studies were presented at the Alzheimer’s Association International Conference. In one, results show that exercise actually reduced tau proteins in patients over the age of 70 with prediabetes and amnestic mild cognitive impairment (6). These are patients considered at very high risk for Alzheimer’s disease.

The patients who saw a benefit did moderate to high intensity aerobic exercise compared to those who did stretching. The key to success in patients who are older (55 to 89 years) was to gradually increase the intensity and duration of exercise over a six-week period until 30 out of 45 minutes were spent at 75 to 85 percent of their maximum heart rate. The frequency of exercise was four days a week. The exercise increased blood flow to areas of the brain typically affected by Alzheimer’s disease.

In another study, results show that walking 40 minutes in addition to warm-up and cool-down periods, totaling one hour of exercise three times a week, could improve cognition in those with vascular cognitive impairment (VCI), another form of dementia (7). This population was composed of 56- to 96-year-olds with mild VCI. The duration of the study was six months.

A third exercise study was a randomized controlled trial (RCT), the gold standard of studies. In this study, participants trained to moderate to intensive aerobic exercise levels, 70 to 80 percent of maximum heart rate (8). The subgroup population that maintained at least an 80 percent adherence to the exercise regimen saw a significant positive change in the Symbol Digit Modalities Test (SDMT), a test used for attention and mental speed, compared to the control. However, the primary end point did not reach statistical significance. There was also an improvement in neuropsychiatric symptoms in the treatment group. These patients trained over a four-month period and had mild to moderate Alzheimer’s disease at baseline. This is the first study to indicate that exercise could have an impact on those with Alzheimer’s disease. The median age was 72 for the treatment group.

The role of diet

In a study, those who had the greatest adherence (top tertile) to the MIND diet were cognitively 7.5 years younger compared to those who had the least adherence (bottom tertile) (9). The MIND diet is a modified combination of the Mediterranean diet and the dietary approach to stop hypertension (DASH) diet. This was a prospective (forward-looking) observational study over a 4.7-year period involving almost 1,000 patients with a mean age of 81 years.

Lifestyle modifications

So far, we have seen the potential benefits of diet and exercise as separate entities. But what if we brought numerous components of lifestyle modifications together? In the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) study, results show that a multidisciplinary approach to lifestyle modifications potentially slowed cognitive decline in a healthy older population (10). The treatment arm participants had a 25 percent improvement in cognitive scores, compared to the control group given health advice only. The lifestyle modifications in the treatment arm included diet, exercise, brain training and management of vascular risk factors. This was a large, 1,260-participant, RCT involving 60- to 70-year-olds over a two-year duration. The population, though healthy, was at risk for mild cognitive impairment.

Testing for risk

In a study involving the Memory Binding Test (MBT), those who did not perform well were at a significantly greater risk of amnestic mild cognitive impairment and dementia (11). This is a test that can be performed in a physician’s office in about 10 minutes. The test involves associative binding between two word lists. Those who do poorly on the test are at 2.5 times increased risk of amnestic mild cognitive impairment and at a greater risk of dementia. The test had good durability with up to a decade of follow-up.

Thus, lifestyle modifications, with or without medications may have powerful effects in preventing and potentially treating mild cognitive decline and dementia.

References:

(1) Lancet. 1997;349(9068):1793; Ann Intern Med. 2008;148(6):427. (2) uptodate.com. (3) AAIC 2015. Posters P4-108. (4) Neurology. Online 2015 Aug 19. (5) J Am Geriatr Soc. 2015;63(8):1512-1518. (6) AAIC 2015. Oral presentations 0504-05. (7) AAIC 2015. Oral presentations 05-04-04. (8) EAN 2015. Abstract O310. (9) Alzheimers Dement. 2015 Jun 15. (10) Lancet. 2015 Jun 6;385(9984):2255-2263. (11) AAIC 2015. Abstract O3-10-04.

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 www.medicalcompassmd.com or consult your personal physician.

Millions of Americans take herbal supplements. In fact, a survey from 2007 showed that 18 percent of Americans used herbal supplements in the previous year (1). Many take them on a daily basis, hoping they will prevent disease, keep them healthy, or even help treat disease, with or without conventional drugs. Many think that herbal supplements, unlike most medications, are natural substances, and therefore are likely to be safe.

Herbs have been used for thousands of years. Hippocrates, the father of medicine, recognized that there may be potential benefits of taking St. John’s wort for the treatment of mood disturbances. Another substance, saw palmetto, was used by the Egyptians for urinary tract problems in the 15th century B.C. (2).

However, even with a long tradition, are they really safe and effective? Even more, are we getting what the label says is in the bottle? Earlier this year, the NYS Attorney General performed DNA tests on 78 bottles of herbal supplements at Target, GNC, Walmart and Walgreens. Eighty percent did not contain the labeled ingredients, and some contained high levels of mercury, arsenic and lead (3). They also contained some substances that patients may be allergic to when the label on the bottle claimed otherwise.

The problem lies with the fact that herbal supplements are self-regulated. Manufacturers must label them with a disclaimer, saying that the content and health claims have not been reviewed by the FDA and that they are not meant to treat or prevent disease. Would you be comfortable buying drugs that were self-regulated? Probably not!

Many think the worst thing that could happen is they don’t help. Unfortunately, this may not be the worst effect. They may or may not work – the research on most is not very compelling. They also may be harmful on several levels: some cause interactions with drugs, such as Coumadin; some are incorrectly labeled regarding contents or doses; some include unlabeled medications in the bottles; and some cause side-effects. Just because they are said to be natural, doesn’t mean they’re safe.

Let’s look at the evidence.

Content of herbal supplements

We want to be certain that the contents in the bottle match what is on the label. Unfortunately, the recent investigation isn’t the first time the issue has been raised. An earlier study found that not all herbal supplements contain what is claimed, and some contain potentially harmful contaminants or inaccurate concentrations. Canadian researchers tested 44 herbal supplements from a dozen companies in the U.S. and Canada (4). They found that only 48 percent contained the herb that was on the label. In addition, about one-third of these supplements also contained fillers or contaminants. For example, a bottle labeled St. John’s wort actually contained a laxative from a plant called Alexandrian senna, and no St. John’s wort. With two other popular herbs, ginkgo biloba, used for memory, and echinacea, used to treat or prevent colds, there were fillers and potentially harmful contaminants in the bottles. These were identified using a sensitive DNA testing technique called DNA barcoding.

Black Cohosh

Black cohosh is used by women to help treat vasomotor symptoms, specifically, hot flashes associated with menopause. In a local study done at Stony Brook University Medical Center, as many as 25 percent of the bottles tested did not contain black cohosh (5). They tested 36 bottles acquired from brick-and-mortar chain stores and online. David Baker, M.D., an Obstetrics/Gynecology professor, also utilized the DNA barcoding technique mentioned above.

Ginkgo Biloba

Does ginkgo biloba live up to its claim of helping improve memory or prevent dementia? Unfortunately, in the first, large, double-blinded, randomized controlled trials (RCT), the gold standard of trials, results were disappointing (6). Ginkgo biloba was no better in preventing dementia or Alzheimer’s disease than a placebo. There were more than 3,000 participants in the trial; most did not have cognitive issues, but 14 percent had mild cognitive impairment. The treatment group took 120 mg of ginkgo biloba.

This is only one, albeit large, well-designed, study. But at least this supplement is safe, right? Well, in a toxicology study using lab animals, results demonstrated an increased risk of developing cancer, especially thyroid and liver cancers, as well as nasal tumors (7). Researchers point out that, while this is an interesting finding, it does not mean necessarily that the results are transferable to humans. Also, the doses used in this toxicology study were much higher, when compared to those taken by humans.

Red yeast rice and Phytosterols

Lest you think that herbs are not effective, red yeast rice is an herbal supplement that may be valuable for treating patients with elevated levels of cholesterol. In a study in patients with high cholesterol who refused or had painful muscle side effects from statin treatment, results showed that red yeast rice and lifestyle changes were effective in lowering LDL “bad cholesterol” levels (8). Patients making lifestyle changes alone were able to lose weight and maintain lower LDL levels over one year. The patients taking red yeast rice maintained LDL reductions over the year, as well. When phytosterols were added for patients taking red yeast rice, there was no further improvement in cholesterol levels. Again, some herbs may be effective, while others may not.

Resources

By no means are all herbs suspect, but you need to perform some due diligence. What can be done to make sure that doctors and their patients are more confident that the herbal supplements contain what we think? Well the best would be if an agency like the FDA would oversee these products. However, since that has not happened yet, there are resources available. These include Consumer Labs (www.Consumerlabs.com), Center for Science in the Public Interest (www.CSPInet.org), and NIH National Center for Complementary and Alternative Medicine Herb Fact Sheets (www.nccam.nih.gov/health/herbsataglance.htm), and Natural Medicines Comprehensive Database (www.naturaldatabase.com).

Conclusion

When taking herbal supplements, it is very important that patients share this information, including the brand names and doses, with their doctors and pharmacists. Herbal supplements may interact with medications, but they also may not contain labeled ingredients, and could have detrimental effects. If you have symptoms that are not going away, it could be due to these supplements. The best natural approach is always lifestyle modification.

Herbal supplements are sorely lacking proper regulation. So caveat emptor — buyer beware when it comes to taking herbal supplements.

References:

(1) Natl Health Stat Report. 2008. (2) JAMA. 1998;280(18):1604. (3) NYTimes.com. (4) BMC Medicine 2013, 11:222. (5) J AOAC Int. 2012 Jul-Aug;95(4):1023-34. (6) JAMA 2008;300:2253. (7) ntp.niehs.nih.gov. (8) Am Heart J. 2013;166(1):187-196.

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 www.medicalcompassmd.com or consult your personal physician.

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

However, another, more recently 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 say that obesity has reached a new milestone.

There are now more obese patients in the United States, 67.6 million, compared to those who are overweight, 65.2 million. 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 25. This should be an eye-opener. In fact, the researchers go even further to estimate that from the 1988-1994 survey to the 2007-2012 survey NHANES data show that 8 percent more women and 12 percent more men became overweight or obese.

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 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 greater than 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 beneficial impact on breast cancer.

Why might this be the case with cancer and obesity?

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).

What can we do?

There is a potentially simple step that obese cancer patients may be able to take — the addition of vitamin D. In a recent 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. Recently, 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 recent 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 jumpstart the process, accelerate progress or to help maintain your desired weight. Choose wisely with the help of your physician.

References:

(1) JAMA 2014;311:806-814. (2) JAMA Intern Med 2015;175(8):1412-1413. (3) Am J Public Health 2015;105(9):e54-9. (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 8(7):1-8. 2015 (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, go to the website www.medicalcompassmd.com or consult your personal physician.

Dehydration is a topic that is often overlooked or given only cursory thought, but it’s very important. Dehydration is simple to avoid, right? Not necessarily. The problem is that we may be dehydrated prior to experiencing symptoms of thirst. In the heat of summer or while exercising, you’re more likely to think about hydration, though you may not actually hydrate enough; however, it’s relevant year-round. Complications and symptoms of dehydration can be mild to severe, ranging from constipation, mood changes, headaches and heart palpitations to heat stroke, migraines and heart attacks.

Effect on headaches and migraines

Temperature is a potential trigger for headaches and migraines. As the temperature rises by intervals of nine degrees, the risk for headaches and migraines increases by 8 percent (1). This study involved 7,054 participants from one emergency room site. Warmer temperatures can potentially reduce blood volume in the body, causing dilation of the arteries, resulting in higher risk of headaches and migraines.

In another study, those who drank four cups more water per day had significantly fewer hours of migraine pain than those who drank less (2). Headache intensity decreased as well. Anecdotally, I had a patient who experienced a potentially dehydration-induced migraine after playing sports in the sweltering heat. He had the classic aura and was treated with hydration, acetaminophen and caffeine, which helped avoid much of the suffering.

Impact on heart palpitations

Heart palpitations are very common. They are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise are contributing factors (3). They occur mainly when we don’t hydrate prior to exercise. All we need to do is drink one glass of water prior to exercise and then drink during exercise to avoid palpitations. Though these are not usually life-threatening, they are anxiety-producing for patients.

Heart attacks

The Adventist Health Study, an observational study, showed a dose-response curve for men (4). In other words, group 1, which drank >five glasses of water daily, had the least risk of death from heart disease than group 2, which drank >three glasses of water daily. Those in group 3, which drank <two glasses per day, saw the least amount of benefit, comparatively. For women, there was no difference between groups 1 and 2; however, both fared better than group 3. The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrogen, a substance that helps clots form.

Stroke outcomes

Researchers at Johns Hopkins presented findings at the International Stroke Conference 2015 that suggest dehydrated stroke patients have a four times increased risk of having more severe outcomes between hospital admission and discharge than those without dehydration.

Dehydrated patients who presented to the emergency room within 12 hours of an ischemic (low blood flow caused usually by a clot) stroke had poorer outcomes four days later than those who were not dehydrated (5). Stroke severity was similar between the two groups, and none of these patients had kidney failure. The researchers used National Institutes of Health Stroke Scale (NIHSS) to assess daily stroke severity and used magnetic resonance imaging to calculate the number of resulting brain lesions.

The authors suggest that additional research is necessary to determine appropriate methods for rehydration that will avoid exacerbating some underlying medical conditions, like congestive heart failure.

There were some limitations of this study, including its small size, 126 patients, use of indirect markers to measure dehydration and varied MRI timing. It was also not clear whether the dehydration may have caused the strokes, or whether they were a result of medications that negatively affect the kidneys (6).

In an editorial response Dr. Jeffrey Berns, the editor-in-chief of Medscape Nephrology, noted that the above study was not one of dehydration but rather one of volume depletion (7). This is important because you can treat with the wrong substance and cause a negative effect. Dehydration results in elevated sodium in the blood and increased serum osmolarity, turning it a dark color — not to be confused with certain foods or medications that can color your urine.

However, volume depletion is a clinical diagnosis that might affect kidneys by raising the BUN/creatine ratio. If you treat the latter with water, you may cause low blood levels of sodium, which can be dangerous. Interestingly, in my clinical practice, I treat volume depletion and dehydration similarly with smoothies that predominantly contain fruits and vegetables. Regardless of which diagnosis, you may be able to treat with fluids that contain electrolytes, particulates and that are nutrient-dense.

Mood and energy levels

One small study found that mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women (8). In this small study, the mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise. I would also suggest, from my practice experience, hydration prior to exercise.

Different ways to remain hydrated

Now we realize we need to stay hydrated, but how do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data but did not find adequate studies to suggest that eight glasses is supported in the literature (9). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. A nutrient-dense diet, like the Mediterranean or DASH diets, has a plant-rich focus. A study mentions that diets with a focus on fruits and vegetables increases water consumption (10). As you may know, up to 95 percent of fruit and vegetable weight can be attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

The myth: Coffee is dehydrating

In one review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (11). With moderate amounts of caffeine, the beverage has a more hydrating effect than the diuretic effect.

Thus, it is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high amounts of nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (12).

References:

(1) Neurology 2009 Mar 10;72(10):922-927. (2) Handb Clin Neurol 2010;97:161-172. (3) Clevelandclinic.org. (4) Am J Epidemiol 2002 May 1; 155:827-833. (5) International Stroke Conference (ISC) 2015. Abstract T MP86. Presented Feb. 12, 2015. (6) Medscape Feb. 19, 2015. (7) Medscape Mar. 27, 2015. (8) J. Nutr. Feb. 2012 142:382-388. (9) AJP -Regu Physiol 2002;283(3):R993-R1004. (10) Am J Lifestyle Med 2011;5(4):316-319. (11) Exerc Sport Sci Rev 2007;35(3):135-140. (12) Br J Ophthalmol 2005:89:1298-1301.

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 www.medicalcompassmd.com or consult your personal physician.

Cancer, a word that for decades was whispered as taboo, has become front and center in the medical community. Cancer is the number one killer of Americans, at least those <85 years old, even ahead of cardiovascular disease (1). We have thought that diet may be an important component in preventing cancer. Is diet a plausible approach?

An article published in the New York Times, entitled “An Apple a Day and Other Myths,” questions the validity of diet in the prevention of cancer. This article covers cancer in general, which is a huge and daunting topic.

The article’s author references a comment by Walter Willet, M.D., a professor and chair of the Harvard School of Public Health’s Epidemiology and Nutrition Department as indicating that the research is inconsistent when it comes to fruits and vegetables. The article goes on to state that even fiber and fats may not play significant roles in cancer.

I don’t necessarily disagree with their assessment. However, I would like to emphasize that Dr. Willet also commented that there are no large, well-controlled diet studies. This leaves the door open for the possibility that diet does have an impact on cancer prevention. I would like to respond.

As Dr. Willet hinted, the problem with answering this question may lie with the studies themselves. The problem with diet studies in cancer, in particular, is that they rely mainly on either retrospective (backward-looking) or prospective (forward-looking) observational studies.

Observational studies have many weaknesses. Among them is recall bias, or the ability of subjects to remember what they did. Durability is also a problem; the studies are not long enough, especially with cancer, which may take decades to develop. Confounding factors and patient adherence are other challenges, as are the designs and end points of the studies (2). Plus, randomized controlled trials are very difficult and expensive to do since it’s difficult and much less effective to reduce the thousands of compounds in food into a focus on one nutrient. Let’s look at the evidence.

The EPIC trial
Considered the largest of the nutrition studies is the European Prospective Investigation into Cancer and Nutrition (EPIC). It is part of what the author is using to demonstrate his point that fruits and vegetables may not be effective, at least in breast cancer. This portion of the study involved almost 300,000 women from eight different European nations (3). Results showed that there was no significant difference in breast cancer occurrence between the highest quintile of fruit and vegetable consumption group compared to the lowest. The median duration was 5.4 years.
Does this study place doubt in the diet approach to cancer? Possibly, but read on. The most significant strength was its size. However, there were also many weaknesses. The researchers were trying to minimize confounding factors, but there were eight countries involved, with many different cultures, making it almost impossible to control. It is not clear if participants were asked what they were eating more often than at the study’s start. Risk stratification was also not clear; which women, for example, might have had a family history of the disease.

Beneficial studies with fruits and vegetables
Also using the same EPIC study, results showed that fruit may have a statistically significant impact on lung cancer (4). Results showed that there was a 40 percent decrease in the risk of developing lung cancer in those that were in the highest quintile of fruit consumption, compared to those in the lowest quintile. However, vegetables did not have an impact. The results were most pronounced in the northern European region. I did say the answer was complex.
Ironically, it seems that some other studies, mostly smaller studies, show potentially beneficial effects from fruits and vegetables. This may be because it is very difficult to run an intensive, well-controlled, large study.

Prostate cancer
Dean Ornish, M.D., a professor of medicine at UC San Francisco Medical School, has done several well-designed pilot studies with prostate cancer. His research has a focus on how lifestyle affects genes. In one of the studies, results of lifestyle modifications showed a significant increase in telomere length over a five-year period (5).
Telomeres are found on the end of our chromosomes; they help prevent the cell from aging, becoming unstable and dying. Shorter telomeres may have an association with diseases, such as cancer, aging and morbidity (sickness). Interestingly, the better patients adhered to the lifestyle modifications, the more telomere growth they experienced. However, in the control group, telomeres decreased in size over time. There were 10 patients in the lifestyle (treatment) group and 25 patients in the control group — those who followed an active surveillance-only approach.
In an earlier study with 30 patients, there were over 500 changes in gene expression in the treatment group. Of these, 453 genes were down-regulated, or turned off, and 48 genes were up-regulated, or turned on (6). The most interesting part is that these changes in gene transcription occurred over just a three-month period with lifestyle modifications.
In both studies, the patients had prostate cancer that was deemed at low risk of progressing into advanced or malignant prostate cancer. These patients had refused immediate conventional therapy including hormones, radiation and surgery. In both studies, the results were determined by prostate biopsy. These studies involved intensive lifestyle modifications that included a low-fat, plant-based, vegetable-rich diet. But as the researchers pointed out, there is a need for larger randomized controlled trials to confirm these results.

Cruciferous vegetables
A meta-analysis involving a group of 24 case-control studies and 11 observational studies, both types of observational trials, showed a significant reduction in colorectal cancer (7). This meta-analysis looked at the effects of cruciferous vegetables, also sometimes referred to as dark-green, leafy vegetables.
In another study that involved a case-control observational design, cruciferous vegetables were shown to significantly decrease the risk of developing multiple cancers, including esophageal, oral cavity/pharynx, breast, kidney and colorectal cancer (8). There was also a trend that did not reach statistical significance for preventing endometrial, prostate, liver, ovarian and pancreatic cancers. The most interesting part is that the comparison was modest, contrasting consumption of at least one cruciferous vegetable a week with none or less than one a month. However, we need large, randomized trials using cruciferous vegetables to confirm these results.
In conclusion, it would appear that the data are mixed in terms of the effectiveness of fruit and vegetables in preventing cancer or its progression. The large studies have flaws, and pilot studies require larger studies to validate them. However, imperfect as they are, there are results that indicate that diet modification may be effective in preventing cancer. I don’t think we should throw out the baby with the bath water.
There is no reason not to consume significant amounts of fruits and vegetables in the hopes that it will have positive effects on preventing cancer and its progression. There is no downside, especially if the small studies are correct.

References:
(1) CA Cancer J Clin. 2011;61(4):212. (2) Nat Rev Cancer. 2008;8(9):694. (3) JAMA. 2005;293(2):183-193. (4) Int J Cancer. 2004 Jan 10;108(2):269-276. (5) Lancet Oncol. 2013 Oct;14(11):1112-1120. (6) Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369-8374. (7) Ann Oncol. 2013 Apr;24(4):1079-1087. (8) Ann Oncol. 2012 Aug;23(8):2198-2203.

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 www.medicalcompassmd.com or consult your personal physician.