It seems like everyone has heard of hypothyroidism. But do we really know what it is and why it is important? The thyroid is a butterfly-shaped organ responsible for maintaining our metabolism. It sits at the base of the neck, just below the laryngeal prominence or Adam’s apple. The prefix “hypo,” derived from Greek, means “under” (1). Therefore, hypothyroidism indicates an underactive thyroid and results in slowing of the metabolism. Many people get hypo- and hyperthyroidism confused, but they are complete opposites.

Blood tests determine if a person has hypothyroidism; they include thyroid stimulating hormone, which is usually increased, thyroxine (free T4), and triiodothyronine (free T3 or T3 uptake), which may both be suppressed (2).

There are two types of primary hypothyroidism: subclinical and overt. In the overt (more obvious) type, classic symptoms include weight gain, fatigue, thinning hair, cold intolerance, dry skin, and depression, as well as the changes in all three thyroid hormones on blood tests mentioned above. In the subclinical, there are may be less obvious or vague symptoms and only changes in the TSH. The subclinical can progress to the overt stage rapidly in some cases (3).  Subclinical is substantially more common than overt; its prevalence may be as high as 10 percent of the U.S. population (4).

What are potential causes or risk factors for hypothyroidism? There numerous factors, such as medications, including lithium; autoimmune diseases, whether personal or in the family history; pregnancy, though it tends to be transient; and treatments for hyperthyroidism (overactive thyroid), including surgery and radiation.

The most common type of hypothyroidism is Hashimoto’s thyroiditis (5). This is where antibodies attack thyroid gland tissues. Several blood tests are useful to determine if a patient has Hashimoto’s: thyroid peroxidase antibodies and antithyroglobulin antibodies.

Synopsis

I would like to separate the myths from the realities with hypothyroidism. Does treating hypothyroidism help with weight loss? Not necessarily. Is soy potentially bad for the thyroid? Yes. Does coffee affect thyroid medication? Maybe. Does subclinical hypothyroidism negatively impact cholesterol? There are studies that suggest this. And finally, do vegetables, specifically cruciferous vegetables, negatively impact the thyroid? Probably not. Let’s look at the evidence.

Treatments: medications and supplements

When it comes to hypothyroidism, there are two main medications: levothyroxine and Armour Thyroid. The difference is that Armour Thyroid converts T4 into T3, while levothyroxine does not. Therefore, one medication may be more appropriate than the other, depending on the circumstance. However, T3 can be given with levothyroxine, which is similar to using Armour Thyroid.

What about supplements? A recent study tested 10 different thyroid support supplements; the results were downright disappointing, if not a bit scary (6). Of the supplements tested, 90 percent contained actual medication, some to levels higher than what are found in prescription medications. This means that the supplements could cause toxic effects on the thyroid, called thyrotoxicosis. Supplements are not FDA-regulated, therefore they are not held to the same standards as medications. There is a narrow therapeutic window when it comes to the appropriate medication dosage for treating hypothyroidism, and it is sensitive. Therefore, if you are going to consider using supplements, check with your doctor and tread very lightly.

Soy impact

What role does soy play with the thyroid? In a randomized controlled trial, the gold standard of studies, the treatment group that received higher amounts of soy supplementation had a threefold greater risk of conversion from subclinical hypothyroidism to overt hypothyroidism than those who received considerably less supplementation (7). Thus, it seems that in this small yet well-designed study, soy has a negative impact on the thyroid. Therefore, those with hypothyroidism may want to minimize or avoid soy. Interestingly, those who received more soy supplementation did see improvements in blood pressure and inflammation and a reduction in insulin resistance but, ultimately, a negative impact on the thyroid.

The reason that soy may have this negative impact was illustrated in study involving rat thyrocytes (thyroid cells) (8). Researchers found that soy isoflavones, especially genistein, which are usually beneficial, may contribute to autoimmune thyroid disease, such as Hashimoto’s thyroiditis. They also found that soy may inhibit the absorption of iodide in the thyroid.

Weight loss

Since being overweight and obese is a growing epidemic, wouldn’t it be nice if the silver lining of hypothyroidism is that, with medication to treat the disease, we were guaranteed to lose weight? In a recent retrospective (looking in the past) study, results showed that only about half of those treated with medication for hypothyroidism lost weight (9). This has to be disappointing to patients. However, this was a small study, and we need a large randomized controlled trial to test it further.

WARNING: The FDA has a black box warning on thyroid medications — they should never be used as weight loss drugs (FDA.gov). They could put a patients in a hyperthyroid state and worse, have potentially catastrophic results.

Coffee

I am not allowed to take away my wife’s coffee; she draws the line here with lifestyle modifications. So I don’t even attempt to with my patients, since coffee may have some beneficial effects. But when it comes to hypothyroidism, taking levothyroxine and coffee together may decrease the absorption of levothyroxine significantly (10). It did not seem to matter whether they were taken together or an hour apart. This was a very small study involving only eight patients. Still, I recommend avoiding coffee for several hours after taking the medication. This should be okay, since the medication must be taken on an empty stomach.

Vegetables

There is a theory that vegetables, specifically cruciferous ones, may exacerbate hypothyroidism. In one animal study, results suggested that very high intake of these vegetables does reduce thyroid functioning (11). This study was done over 30 years ago, and it has not been had replicated.

Importantly, this may not be the case in humans. In the recently published Adventist Health Study-2, results showed that those who had a vegan-based diet were less likely to develop hypothyroidism than those who ate an omnivore diet (12). And those who added lactose and eggs to the vegan diet also had a small increased risk of developing hypothyroidism. However, this trial did not focus on raw cruciferous vegetables, which is much needed.

There are two take-home points: try to avoid soy products and don’t think that supplements that claim to be thyroid support are good for you or harmless because they are over the counter and “natural.” In my experience, an anti-inflammatory diet helps improve quality of life issues, especially fatigue and weight, for those with Hashimoto’s thyroiditis.

References:

(1) dictionary.com. (2) nlm.nih.gov. (3) Endocr Pract. 2005;11:115-119. (4) Arch Intern Med. 2000;160:526-534. (5) mayoclinic.org. (6) Thyroid. 2013;23:1233-1237. (7) J Clin Endocrinol Metab. 2011 May;96:1442-1449. (8) Exp Biol Med (Maywood). 2013;238:623-630. (9) American Thyroid Association. 2013;Abstract 185. (10) Thyroid. 2008;18:293-301. (11) Crit Rev Food Sci Nutr. 1983;18:123-201. (12) Nutrients. 2013 Nov. 20;5:4642-4652.

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 medicalcompassmd.com and/or consult your personal physician.

Gluten has been gaining in notoriety over the last several years. When we hear someone mention a gluten-free diet, several things tend to come to mind. One may be that this is a healthy diet. Along the same lines, we may think gluten is bad for us. However, gluten-free is not necessarily synonymous with healthy. There are many beneficial products containing gluten.

We might think that gluten-free diets are a fad, like low-fat or low-carb diets. Still, we keep hearing how more people feel better without gluten. Could this be a placebo effect? What is myth and what is reality in terms of gluten? In this article I will try to distill what we know about gluten and gluten-free diets, who may benefit and who may not.

But first, what is gluten? Most people I ask don’t know the answer, which is OK; it is part of the reason I am writing the article. Gluten is a plant protein found mainly in wheat, rye and barley.

Now to answer the question of whether going gluten-free is a fad. The answer is resounding “No,” since we know that patients who suffer from celiac disease, an autoimmune disease, benefit tremendously when gluten is removed.(1) In fact, it is the main treatment.

But what about people who don’t have celiac disease? There seems to be a spectrum of physiological reaction to gluten, from intolerance to gluten (sensitivity) to gluten tolerance (insensitivity). Obviously, celiac disease is the extreme of intolerance, but even these patients may be asymptomatic. Then, there is nonceliac gluten sensitivity, referring to those in the middle portion of the spectrum.(2) The prevalence of NCGS is half that of celiac disease, according to the NHANES data from 2009-2010.(3) However, many disagree with this assessment, indicating that it is much more prevalent and that its incidence is likely to rise.(4) The term was not even coined until 2011.

What is the difference between full-blown celiac disease and gluten sensitivity? They both may have intestinal symptoms, such as bloating, gas, cramping and diarrhea, as well as extraintestinal (outside the gut) symptoms, including gait ataxia (gait disturbance), malaise, fatigue and attention deficit disorder.(5) Surprisingly, they both may have the same results with serological (blood) tests, which may be positive or negative. The first line of testing includes antigliadin antibodies and tissue transglutaminase. These measure a reaction to gluten; however, they don’t have to be positive to have reaction to gluten. HLA–DQ phenotype testing is the second line of testing and tends to be more specific for celiac disease.

What is unique to celiac disease is a histological change in the small intestine, with atrophy of the villi (small fingerlike projections) contributing to gut permeability, what might be called “leaky gut.” Biopsy of the small intestine is the most definitive way to diagnose celiac disease.

Though the research has mainly focused on celiac disease, there is some evidence that shows NCGS has potential validity, especially in irritable bowel syndrome.

Before we look at the studies, what does it mean when a food says it’s “gluten-free”? Well, the FDA has recently weighed in by passing regulation that requires all gluten-free foods to have no more than 20 parts per million of gluten.(6) The agency has given food manufacturers a year to comply with the new standards. Now, let’s look at the evidence.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a nebulous disease diagnosed through exclusion, and the treatments are not obvious. That is why the results from a randomized controlled trial, the gold standard of studies, showing that a gluten-free diet significantly improved symptoms in IBS patients, is so important.(7) Patients were given a muffin and bread on a daily basis.

Of course, one group was given gluten-free products and the other given products with gluten, though the texture and taste were identical. In six weeks, many of those who were gluten-free saw the pain associated with bloating and gas mostly resolve; significant improvement in stool composition, such that they were not suffering from diarrhea; and their fatigue diminished. In fact, in one week, those in the gluten group were in substantially more discomfort than those in the gluten-free group. There were 34 patients involved in this study.

As part of a well-written March 4, 2013 editorial in Medscape, by David Johnson, M.D., a professor of gastroenterology at Eastern Virginia Medical School, he questions whether this beneficial effect from the IBS trial was due to gluten withdrawal or to withdrawal of fermentable sugars because of the elimination of some grains, themselves.(8) In other words, gluten may be just one part of the picture. He believes that nonceliac gluten sensitivity is a valid concern.

Autism

Autism is a very difficult disease to quantify, diagnose and treat. Some have suggested gluten may play a role. Unfortunately, in a study with children who had autism spectrum disorder and who were undergoing intensive behavioral therapy, removing both gluten and casein, a protein found in dairy, had no positive impact on activity or sleep patterns.(9) These results were disappointing. However, this was a very small study involving 22 preschool children. Removing gluten may not be a panacea for all ailments.

Antibiotics

The microbiome in the gut may play a pivotal role as to whether a person develops celiac disease. In an observational study using data from the Swedish Prescribed Drug Register, results indicate that those who were given antibiotics within the last year had a 40 percent greater chance of developing celiac disease and a 90 percent greater risk of developing inflammation in the gut.(10) The researchers believe that this has to do with dysbyosis, a misbalance in the microbiota, or flora, of the gastrointestinal tract. It is interesting that celiac disease may be propagated by change in bacteria in the gut from the use of antibiotics.

Not everyone will benefit from a gluten-free diet. In fact, most of us will not. Ultimately, people who may benefit from this type of diet are those patients who have celiac disease and those who have symptomatic gluten sensitivity. Also patients who have positive serological tests, including tissue transglutaminase or antigliadin antibodies are good candidates for gluten-free diets.

There is a downside to a gluten-free diet: potential development of macronutrient and micronutrient deficiencies. Therefore, it would be wise to ask your doctor before starting gluten withdrawal. The research in patients with gluten sensitivity is relatively recent, and most gluten research has to do with celiac disease. Hopefully, we will see intriguing studies in the near future, since gluten-free products have grown to a $4 billion industry that the FDA now has begun to regulate.

References:

(1) Am J Gastroenterol. 2013;108:656-676. (2) Gut 2013;62:43–52. (3) Scand J Gastroenterol. (4) Neurogastroenterol Motil. 2013 Nov;25(11):864-71. (5) medscape.com. (6) fda.gov. (7) Am J Gastroenterol. 2011; 106(3):508-14. (8) medscape.com. (9) 9th annual AIM for Autism Research 2010; abstract 140.007. (10) BMC Gastroenterol. 2013:13(109).

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 medicalcompassmd.com or consult your personal physician.

Atrial fibrillation is the most common arrhythmia, an abnormal or irregular heartbeat, found in the U.S. Unfortunately, it is very complicated to treat. Though there are several options, including medications and invasive procedures, it mostly boils down to symptomatic treatment, rather than treating or reversing underlying causes.

What is AFib? It is an electrical malfunction that affects the atria, the two upper chambers of the heart, causing them to beat “irregularly irregular,” or with no set pattern affecting the rhythm and potentially causing a rapid rate. The result of this may be insufficient blood supply throughout the body.

Complications that may occur can be severely debilitating, such as stroke or even death. Its prevalence is expected to more than double in the next 16 years (1). Risk factors include age (the older we get, the higher the probability), obesity, high blood pressure, premature atrial contractions and diabetes.

AFib is not always symptomatic; however, when it is symptoms include shortness of breath, chest discomfort, light-headedness, fatigue and confusion. This arrhythmia can be diagnosed by electrocardiogram, but more likely with a 24-hour halter monitor. The difficulty in diagnosing AFib sometimes is because it can be intermittent.

There may be a better way to diagnose AFib. In a recent study, the Zio patch, worn for 14 days, was more likely to show arrhythmia than a 24-hour halter monitor (2). The Zio patch is a waterproof adhesive patch on the chest, worn like a Band-Aid, with one ECG lead.  While 50 percent of patients found the halter monitor to be unobtrusive, almost all patients found the Zio patch comfortable.

There are two main types of AFib, paroxysmal and persistent. Paroxysmal is acute, or sudden, and lasts for less than seven days, usually less than 24 hours. It tends to occur with greater frequency over time, but comes and goes. Persistent AFib is when a patient has AFib that continues past seven days (3). AFib is a progressive disease, meaning it only gets worse especially without treatment.

Medications are meant to treat either the rate or rhythm or prevent strokes from occurring. Medications that treat rate include beta blockers, like metoprolol, and calcium channel blockers, such as diltiazem (Cardizem). Examples of medications that treat rhythm are amiodarone and sotalol. Then there are anticoagulants that are meant to prevent stroke, such as warfarin and some newer medications, dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). The newer anticoagulants are easier to administer, but may have higher bleeding risks in some circumstances with no antidote.

There is also an invasive procedure, ablation, that requires threading a catheter through an artery, usually the femoral artery located in the groin, to reach the heart. In one type of ablation, the inappropriate nodes firing in the walls of the atria are ablated, or destroyed, using radiofrequency. This procedure causes scarring of the tissue in the atria. When successful, patients may no longer need medication. Let’s look at the evidence.

Premature atrial contractions

Premature atrial contractions, abnormal extra beats that occur in the atrium, may be a predictor of atrial fibrillation. In a recent study, PACs alone, when compared to the Framingham AF risk algorithm (a conglomeration of risk factors that excludes PACs) resulted in higher risk of AFib (4). When there were greater than 32 abnormal beats/hour, there was a significantly greater risk of AFib after 15 years of PACs. When taken together, PACs and the Framingham model were able to predict AFib risk better at 10 years out as well. Also, overall when the number of PACs doubled in patients, there was a 17 percent increased risk of AFib.

The role of obesity

There is good news and bad news with obesity in regards to AFib. Let’s first talk about the bad news. In studies, those who are obese are at significantly increased risk. In the Framingham Heart Study, the risk of developing AFib was 52 percent greater in men who were obese and 46 percent greater in women who were obese when compared to those of normal weight (5). Obesity was a BMI >30 kg/m2, and normal weight was a BMI <25 kg/m2. There were over 5,000 participants in this study with a follow-up of 13 years.

The Danish Diet, Cancer and Health Study reinforces these results by showing that obese men were at a greater than twofold increased risk of developing AFib, and obese women were at a twofold increased risk (6).

Now the good news: weight loss may help reduce the frequency of AFib episodes. That’s right, weight loss could be a simple treatment for this very dangerous arrhythmia. In a recent randomized controlled trial, the gold standard of studies, those in the intervention group lost significantly more weight, 14 kg (32 pounds) versus 3.6 kg (eight pounds), and saw a significant reduction in atrial fibrillation severity score compared to those in the control group (7). There were 150 patients involved in the study.

AFSS includes duration, severity and frequency of atrial fibrillation. All three components in the AFSS were reduced in the intervention group compared to the control group. There was a 692-minute decrease in the time spent in AFib over 12 months in the intervention arm, whereas there was 419-minute increase in the time in AFib in the control group. These results are potentially very powerful; this is the first study to demonstrate that managing risk factors may actually help manage the disease.

Caffeine

According to a recent meta-analysis (a group of six population-based studies) done in China, caffeine does not increase, and may even decrease, the risk of AFib (8). The study did not reach statistical significance. The authors surmised that drinking coffee on a regular basis may be beneficial because caffeine has antifibrosis properties. Fibrosis is the occurrence of excess fibrous tissue, in this case, in the atria, which most likely have deleterious effects. Atrial fibrosis could be a preliminary contributing step to AFib. Since these were population-based studies, only an association can be made with this discovery, rather than a hard and fast link. Still this is a surprising result.

However, in those who already have AFib, it seems that caffeine may exacerbate the frequency of symptomatic occurrences, at least anecdotally. With my patients, when we reduce or discontinue substances that have caffeine, such as coffee, tea and chocolate, the number of episodes of AFib seems to decline. I have also heard similar stories from my colleagues and their patients. So think twice before running out and getting a cup of caffeinated coffee if you have AFib.  What we really need are RCT studies done in patients with AFib, comparing people who consume caffeine regularly to those who have decreased or discontinued the substance.

The bottom line is this: if there were ever a reason needed for obese patients to lose weight, treating atrial fibrillation should be on the top of the list, especially since it is such a dangerous disease with potentially severe complications.

References:

(1) Am J Cardiol. 2013 Oct. 15;112:1142-1147. (2) Am J Med. 2014 Jan.;127:95.e11-7. (3) Uptodate.com. (4) Ann Intern Med. 2013;159:721-728. (5) JAMA. 2004;292:2471-2477. (6) Am J Med. 2005;118:489-495. (7) JAMA. 2013;310:2050-2060. (8) Canadian J Cardiol online. 2014 Jan. 6.

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 medicalcompassmd.com and/or consult your personal physician.

A few weeks ago, a patient walked in to my office with a newspaper article touting the release of new guidelines for the treatment of hypertension, or high blood pressure. The patient wanted to get my feedback on these guidelines released on Dec. 18, 2013, by the Eighth Joint National Committee (JNC 8). The big change is that treatment levels are relaxed. The previous version, JNC 7, was released a decade ago in 2003. Usually they are updated every five or six years, and it has been 10.

My initial reaction was excitement: the JNC 8 was trying to avoid the pitfalls of overtreatment, especially for older patients and those with diabetes and/or chronic kidney disease. However, it’s more complicated than that.

High blood pressure may lead to unwanted consequences, such as cardiovascular events (strokes and heart attacks), heart failure and premature death. The goal of treatment, whether with medication and/or lifestyle changes, is to prevent these complications from developing and, ultimately, lowering risk. Does raising the initial treatment levels impact these goals? Let’s look at the guidelines in more detail.

Previously, anyone with a blood pressure >140/90 mmHg was considered to have elevated levels. However, this is not the case with JNC 8 (1). According to the guidelines, people who are greater than 60 years old should not start blood pressure medications until their levels are >150/90 mmHg. Thus, the parameters for the treatment of systolic blood pressure, the top number, representing blood pumping from the heart to the rest of the body, was relaxed by 10 mmHg. The authors warn that this is not an opportunity to let the SBP rise above 150 mmHg. If you already are well controlled with blood pressure medications, the authors advise not changing the regimen.

For those who have diabetes or chronic kidney disease, the target goal for treatment also became more lenient, rising from a SBP of <130 mmHg to a suggested level of <140 mmHg. To make things a little more confusing, the guidelines go on to say that it is unclear what the cutoff for SBP should be to start treatment for those under 60.

There was dissension in the JNC 8 ranks relating to age. Though the American Society of Hypertension and the International Society of Hypertension agree that the initial treatment target should be changed, it should only be changed for those who are greater than 80 years of age, not older than 60 (2).

The reason for the less strict cutoff to treat high blood pressure is based on the dearth of randomized controlled trials for those who are greater than 60 years of age. In fact, there are only two RCT studies for this age group and only one RCT for patients greater than 80 years old. Obviously, we need more studies that focus on older populations, especially since our population is aging. Also, ironically, JNC 8 loosened SBP treatment levels for the population at greatest risk. Approximately two-thirds of patients greater than 60 years old will develop high blood pressure (3).

The easing of guidelines with diabetes patients was influenced by the results from the ACCORD trial, a large RCT (4). One part of the trial involved researchers looking at intensive treatment of SBP with medications to levels <120 mmHg. The goal was to reduce the risk of cardiovascular events. There were over 4,500 patients involved in this investigation into intensive blood pressure treatment over 4.3 years. After the first year, although they achieved the goal of a SBP of <120 mmHg in the intensive group, clinical outcomes did not pan out. Results showed no significant reduction in death from any cause between the intensive group and the standard treatment group. The conclusion was that intensive therapy had no more benefit than standard therapy for fatal and nonfatal cardiovascular events, though there were significantly more side effects with intensive therapy. This was disappointing.

Dr. Harlan Krumholz, professor of medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, wrote an intriguing article in the New York Times on Dec. 18, 2013, entitled “3 Things To Know About the New Blood Pressure Guidelines” (5). I want to highlight his third point: even though we may lower blood pressure with medications, specifically borderline high blood pressure, it may not reduce subsequent risk of premature death, stroke or heart attacks.

To reduce the risk of cardiovascular events, there are several factors involved. To learn more, please look at my March 13, 2012, article entitled “Seven highly effective habits for preventing heart disease.” Of course, normal blood pressure of <120/80 mmHg is only one component in making cardiovascular disease much less significant (6).

There are a number of studies that show the impact that lifestyle modifications may have on hypertension. A recent population-based study involving over 3,000 participants in Sicily looked at different levels of adherence to the Mediterranean-type diet. Those who were in the top third for compliance noticed significant reductions in the risks for high blood pressure, diabetes and obesity (7). Though population studies are not as stringent as randomized controlled trials, they still can provide an association between diet and potential reduction in disease risk.

In the Nurses’ Health Study, those who followed a healthy lifestyle, including a nutrient-dense approach with significant amounts of fruit and vegetables called the DASH (dietary approaches to stop hypertension) diet, saw an 80% reduction in the risk of developing high blood pressure (8). Though this is an observational study, it is a very large trial with more than 80,000 women followed over a long duration of 14 years.

Though medications may help reduce SBP levels, they may or may not alter the clinical outcomes. Also, the lack of clinical trials in older patients suggests that the new JNC 8 guidelines are an improvement. I am especially impressed with their emphasis on lifestyle modifications; studies indicate that a nutrient-dense diet may reduce SBP to normal levels with hypertension and prevent high blood pressure for those who have yet to develop the disease.

I don’t agree that older patients should live with higher SBP levels just because we don’t have enough studies showing benefit with medications. Nutrient-dense diets, such as the Mediterranean-type and DASH diets, have shown potentially powerful effects with blood pressure control in the population at large. Thus, it behooves physicians to discuss and stress lifestyle changes, such as diet, exercise and smoking cessation. Patients should not stop blood pressure medications without first discussing it with their doctors. These are only guidelines, and each case may be different.

References:

(1) JAMA online. 2013 Dec. 18. (2) J Hypertens. 2014;32:3-15. (3) Circulation. 2013;127:e6-e245. (4) N Engl J Med. 2010;362:1575-1585. (5) nytimes.com. (6) N Engl J Med. 2012;366:321-329. (7) Nutr Metab Cardiovasc Dis online. 2013 Nov. 1. (8) JAMA. 2009;302:401-411.

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 medicalcompassmd.com and/or consult your personal physician.

I couldn’t resist writing one last article about exercise this year. There are some compelling studies that show exercise’s powerful effects in altering our genes. Recent studies show its impact on specific diseases. Last week I referred to its effect on diabetes (“Exercise: optimizing or reducing its effects,” Dec. 12). Exercise has effects on a host of other chronic diseases as well, including kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers.1

There are also studies on simple ways to motivate yourself during exercise. One showed that those who repeat positive mantras like “feels good” while exercising were able to persist in their exercise routines for longer periods.2 To learn more about this, read the Dec. 12 article.

Why is this so important and why am I harping on exercise right before the holidays? Because we are too sedentary, and this is the time of the year when we are inclined to overeat. According to the 2005-06 National Health & Nutrition Examination Survey, we spend more than half our time sitting.3 And this percentage is trending up. Let’s look at the evidence.

Exercise and your genes

While you may be waiting for gene therapy to cure our chronic illnesses, it turns out that exercise may have a significant impact on our genes. No waiting required, this is here and now.

In a recent study, results showed that thousands upon thousands of genes in fat cells were affected when participants exercised.4 The study involved sedentary men and asked them to exercise twice a week by attending a one-hour spin class each time. According to the researchers, the genes impacted were those involved most likely in storing fat and in risk for subsequent diabetes and obesity development. Participants’ gene expression was altered by DNA methylation, the addition of a methyl group made up of a carbon and hydrogens. These participants also improved their biometrics, reducing fat and subsequently shrinking their waist circumferences, and improved their cholesterol and blood-pressure indices.

The effect is referred to as epigenetics, where lifestyle modifications can ultimately lead to changes in gene expression, turning them on and off. Therefore, just because you have been dealt a set a genes from your parents does not mean you can’t alter how a significant number of them act. This has been shown with dietary changes, but this is one of the first studies to show that exercise also has significant impacts on our genes. The amazing thing about this study is that it took only six months to see these numerous gene changes with modest amounts of cardiovascular exercise.

If this was not enough, another study showed substantial gene changes in muscle cells after one workout on a stationary bike.5

Exercise versus drug therapy

We don’t think of exercise as being a drug or having drug effects, but what if it had similar benefits to certain drugs in cardiovascular diseases and mortality risk? A meta-analysis — a group of 57 studies that involved drugs and exercise — showed that exercise potentially has equivalent effects to statins in terms of mortality with secondary prevention of coronary heart disease.6 This means that, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same was true with pre-diabetes — prior to full-blown type 2 diabetes — and the use of metformin or exercise. It didn’t matter which one was used, the drug or the lifestyle change.

However, diuretics, also called water pills, were more effective than exercise in treating heart failure. This is interesting, since diuretics are used mainly for symptomatic relief and are not thought of in terms of mortality. Thus, the takeaway from this study is that exercise is very powerful and should be used in conjunction with therapies for cardiovascular disease, not instead of them. Don’t stop your medication based on the results of one meta-analysis. If you have further questions, always consult your physician.

Kidney stones and exercise

Anyone who has tried to pass a kidney stone knows it can be an excruciating experience. Most of the treatment revolves around pain medication, fluids and waiting for the stone to pass. However, the best way to treat kidney stones is to prevent them. In the Women’s Health Initiative Observational Study, exercise reduced the risk of kidney stones by as much as 31 percent.7 Even better, the intensity of the exercise was irrelevant to its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results. But lesser amounts of exercise also saw substantial reductions. This study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones.

Sex as exercise

We have heard that sex may be thought of as exercise, but is this myth or is there actual evidence? Try to keep a straight face. Well, it turns out this may be true. In the most recent study, published in the prestigious PLoS One journal, researchers found that young healthy couples exert 6 METs — metabolic energy, or the amount of oxygen consumed per kilogram per minute — during sexual activity.8

How does this compare to other activities? Well, we exert about 1 MET while sitting and 8.5 METs while jogging. Sexual activity falls between walking and jogging, in terms of the energy utilized, and thus may be qualified as moderate activity. Men and women burned slightly less than half as many calories with sex as with jogging, burning a mean of 85 calories over about 25 minutes. Who says exercise can’t be fun?

I can’t stress the importance of exercise enough. Although in last week’s article I noted that exercise with more intensity had better results, any exercise is good, as demonstrated with the kidney stone reduction study.

Exercise not only influences the way you feel, but also may influence gene expression and, ultimately, affects the development and prevention of disease. In certain circumstances, it may be as powerful as drugs and in combination may pack a powerful punch. Therefore, instead of just making exercise a New Year’s resolution, make exercise a priority — part of the fabric of your life. It may already be impacting the fabric of your body: your genes.

References: 1 JAMA. 2009;301(19):2024. 2 Med Sci Sports Exerc. 2013 Oct 10. 3 cdc.gov/nchs/nhanes.htm. 4 PLoS Genet. 2013 Jun;9(6):e1003572. 5 Cell Metab. 2012 Mar 7;15(3):405-11. 6 BMJ 2013; 347. 7 JASN online 2013, Dec. 12. 8 PLoS One 8(10): e79342.

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 and/or consult your personal physician.

For most of us, exercise is not a priority during the winter months, especially during the holiday season. We think that it is okay to let ourselves go and that a few more pounds will help insulate us from the cold. We tend to lock ourselves indoors and hibernate. Of course I am exaggerating, but I am trying to make a point. During the winter it is even more important to put exercise at the forefront of our consciousness because, as I mentioned in my Thanksgiving article, we tend to gain the most weight during the Thanksgiving to New Year holiday season [1].

Many times we are told by the medical community to exercise, which of course is sage advice. It seems simple enough; however, the type, intensity level and frequency of exercise may not be defined. For instance, any type of walking is beneficial, right? Well, as a new study that quantifies walking pace notes, some types of walking are better than others. Although physical activity is always a good thing compared to being sedentary.

We know exercise is beneficial for prevention and treatment of chronic disease. But another very important aspect of exercise is the impact it has on specific diseases, such as diabetes and osteoarthritis. Also, certain supplements and drugs may decrease the beneficial effects of exercise. They are not necessarily the ones you think. They include resveratrol and nonsteroidal anti-inflammatory drugs (such as ibuprofen). Let’s look at the evidence.

Walking with a spring in your step

While pedometers give a sense of how many steps you take on a daily basis, more than just this number is important. Intensity, rather than quantity or distance, maybe the primary indicator of the benefit derived from walking.

In the National Walkers’ Health Study, results showed that those who walk with more pace are more likely to decrease their mortality from all causes and to increase their longevity [2]. This is one of the first studies to quantify specific speed and its impact. In the study, there were four groups. The fastest group was almost jogging, walking at a mean pace of less than 13.5 minutes per mile, while the slowest group was walking at a pace of 17 minutes or more per mile.

The slowest walkers had a higher probability of dying, especially from dementia and heart disease. Those in the slowest group stratified even further: those whose pace equaled 24-minute miles or greater had twice the risk of death, compared to those who walked with greater speed.

However, the most intriguing aspect of the study was that there were big differences in mortality reduction in the second slowest category compared to the slowest, which might only be separated by a minute-per-mile pace. So don’t fret: you don’t have to be a speed-walker in order to get significant benefit.

Mind-body connection

The mind also plays a significant role in exercise. When we exercise, we tend to beat ourselves up mentally because we are disappointed with our results. The results of a new study say that this is not the best approach [3]. Researchers created two groups. The first was told to find four positive phrases, chosen by the participants, to motivate them while on a stationary bike and repeat these phrases consistently for the next two weeks while exercising.

Members of the group who repeated these motivating phrases consistently throughout each workout were able to increase their stamina for intensive exercise after only two weeks, while the same could not be said for the control group, which did not use reinforcing phrases.

‘Longevity’ supplement may have negative impact

Resveratrol is a substance that is thought to provide increased longevity through proteins called sirtuin 1. So how could it negate some benefit from exercise? Well it turns out that we need acute inflammation to achieve some exercise benefits, and resveratrol has anti-inflammatory effects. Acute inflammation is short-term inflammation and is different from chronic inflammation, which is the basis for many diseases. In a small randomized controlled study, treatment group participants were given 250 mg supplements of resveratrol and saw significantly less benefit from aerobic exercise over an eight-week period, compared to those who were in the control group [4]. Participants in the control group had improvements in both cholesterol and blood pressure that were not seen in the treatment group.

This was a small study of short duration, although it was well designed.

Impact on diabetes complications

Unfortunately, type 2 diabetes is on the rise, and the majority of these patients suffer from cardiovascular disease. Drugs used to control sugar levels don’t seem to impact the risk for developing cardiovascular disease. So what can be done? In a recent prospective (forward-looking) observational study, results show that diabetes patients who exercise less frequently, once or twice a week for 30 minutes, are at a higher risk of developing cardiovascular disease and almost a 70% greater risk of dying from it than those who exercised at least three times a week for 30 minutes each session. In addition, those who exercised only twice a week had an almost 50% increased risk of all-cause mortality [5].

The study followed over 15,000 men and women with a mean age of 60 for five years. The authors stressed the importance of exercise and its role in reducing diabetes complications.

Fitness age

You can now calculate your fitness age without the use of a treadmill, according to the recent HUNT study [6]. A new online calculator utilizes basic parameters such as age, gender, height, weight, waist circumference and frequency and intensity of exercise, allowing you to judge where you stand with exercise health. This calculator can be found at www.ntnu.edu/cerg/vo2max. The results may surprise you.

Even in winter, you can walk and talk yourself to improved health by increasing your intensity while repeating positive phrases that help you overcome premature exhaustion. Frequency is important as well. Exercise can also have a significant impact on complications of chronic diseases, such as cardiovascular disease and resulting death with diabetes. Take caution when walking outside during winter to avoid black ice, or use a treadmill to walk with alacrity, although getting outside during the day may help you avoid the winter blues.

References

[1] N Engl J Med. 2000;342:861-867. [2] PLoS One. 2013;8:e81098. [3] Med Sci Sports Exerc. 2013 Oct. 10. [4] J Physiol Online. 2013 July 22. [5] Eur J Prev Cardiol Online. 2013 Nov. 13. [6] Med Sci Sports Exerc. 2011;43:2024-2030.

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 and/or consult your personal physician.

Aneurysms are universally feared; they can be lethal and most times are asymptomatic (without symptoms). Yet aneurysms are one of the least well-covered medical disorders in the press. There are numerous types of aneurysms, most of which are named by their location of occurrence, including abdominal, thoracic and cerebral (brain). In this article, I will discuss abdominal aortic aneurysms, better known as a “triple-A,” or AAA. Preventing any type of aneurysm should be a priority.

What is AAA? It is an increase in the diameter of the walls of the aorta in one area, in this case — the abdomen. The aorta is the “water main” for supplying blood to the rest of the body from the heart. Abnormal enlargement weakens the walls and increases the risk that it may rupture. If the aorta ruptures, it causes massive hemorrhaging, or bleeding, and creates a substantial likelihood of death.

The exact incidence of aneurysms is difficult to quantify, since some people may die due to its rupture without an autopsy being done; however, estimates suggest that they occur in 4-9% of the population [1].

The cause of AAA is not known, but it is thought that inflammation and oxidative stress play an important role in weakening smooth muscle in the aorta [2]. The consequence of this is an abnormally enlarged aorta, or AAA.

People who are at highest risk for aneurysms are those over 60 years old [3]. Other risk factors include atherosclerosis, or hardened arteries, high blood pressure, race (Caucasian), gender (male), family history, smoking and having a history of aneurysms in other arteries [4]. Some of these risk factors are modifiable, such as atherosclerosis, high blood pressure and smoking. Men are more than four times more likely to have a AAA [5]. Though males are at a higher risk, females are at a higher risk of having a AAA rupture [6]. So, gender is important for differentiating the incidence, but also the risk of severity.

Is it important to get screened for AAA? The short answer is yes it is important, especially if you have risk factors. You should talk to your physician. Although some people do experience nondescript symptoms, such as pain in the abdomen, back or flank pain [7], the majority of cases are asymptomatic. A smaller AAA is less likely to rupture and can be monitored closely with noninvasive diagnostic tools, such as ultrasound and CT scan.

Sometimes cost is a question when comes to screening, but a recent study showed unequivocally that screening ultimately reduces cost, because of the number of aneurysms that are identified and potentially prevented from rupturing [8].

What are the treatments?

There are no specific medications that prevent or treat abdominal aortic aneurysms. Medications for treating risk factors, such as high blood pressure, have no direct impact on an aneurysm’s size or progression. But the mainstay of treatment is surgery to prevent rupture. Two surgical techniques may be utilized. One approach is the endovascular repair, which is minimally invasive, and the other is the more traditional open surgery [9]. A recent comparison of these approaches in a small randomized controlled trial had similar outcomes: a mortality rate of 25%. This was considered a surprisingly good statistic.

The good news is that surgery has resulted in a 29% reduction in rupture of the AAA [10].

When using the minimally invasive EVAR technique mentioned above, the specialist who performs the surgery may make a difference. A recent study’s results showed that surgeons had better outcomes, in terms of mortality rates and length of hospital stay, compared to interventional radiologists and cardiologists [11]. This was a retrospective (looking in the past) study, which is not the strongest type of trial.

When to watch and wait and when to treat is a difficult question; surgery is not without its complications, and risk of death is higher than many other surgeries. AAA size is the most important factor. In women, AAAs over 5.0 cm may need immediate treatment, while in men, those over 5.5 cm may need immediate treatment [12]. Smaller AAAs, however, are trickier.

The growth rate is important, so patients with this type of aneurysm should have an ultrasound or CT scan every six to 12 months. If you have an aneurysm, have a discussion with your physician about this.

Lifestyle changes

One of the most powerful tools against AAA is prevention; it avoids the difficult decision of how to best avoid rupture and the complications of surgery itself. Lifestyle changes are a must. They don’t typically have dangerous side effects, but rather potential side benefits. These lifestyle changes include smoking cessation, exercise and dietary changes.

Smoking cessation

Smoking has the greatest impact, because it directly impacts the occurrence and size of AAA. It increases risk of medium-to-large size aneurysms by at least fivefold. One study found that smoking was responsible for 78% of aortic aneurysms larger than 4 cm [13]. Remember, size does matter in terms of risk of rupture. So for those who smoke, this is a wake-up call.

Impact of Fruit

A simple lifestyle modification with significant impact is increasing your fruit intake. The results of two prospective (forward-looking) study populations, Cohort of Swedish Men and the Swedish Mammography Cohort Study, showed that consumption of greater than two servings of fruit a day decreased the risk of AAA by 25% [14]. If you do have AAA, this same amount of fruit also decreased the risk of AAA rupture by 43%. This study involved over 80,000 men and women, ages 46 to 84, with a follow-up of 13 years.

The authors believe that fruit’s impact may have to do with its antioxidant properties; it may reduce the oxidative stress that can cause these types of aneurysms. Remember, the quandary has been when the benefit of surgery outweighs the risks, in terms of preventing rupture. This modest amount of fruit on a daily basis may help alleviate this quandary.

So what have we learned? Screening for AAA may be very important, especially as we age and if we have a family history. Surgery results to prevent rupture are similar, regardless of the type. However, keep in mind that surgery for AAA has a significant mortality risk. At the end of the day, lifestyle changes, including smoking cessation and increased fruit intake, are no-brainers.

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 and/or consult your personal physician.

Many of us give thanks for our health on Thanksgiving. Well, let’s follow through with this theme. While eating healthy may be furthest from our minds during a holiday, it is so important.

Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and increase your risk for chronic diseases, you can reverse this trend while staying in the traditional theme of what it means to enjoy a festive meal.

What can we do to turn Thanksgiving into a bonanza of good health? Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. Carotenoids make up a family of greater than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (Crit Rev Food Sci Nutr 2010;50(8):728–760).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer; amyotrophic lateral sclerosis, also as Lou Gehrig’s disease; age-related macular degeneration, cardiovascular disease — heart disease and stroke. Foods that contain these substances are orange, yellow and red vegetables and fruits, and dark green leafy vegetables. Examples include sweet potato, acorn squash, summer squash, spaghetti squash, green beans, carrots, cooked pumpkin, spinach, kale, papayas, tangerines, tomatoes and brussels sprouts. Let’s look at the evidence.

Breast cancer effect

We know that breast cancer risk is high among women, especially on Long Island. The risk for a woman is 12.4 percent getting breast cancer in their lifetime (SEER Cancer Statistics Review, 1975–2009, National Cancer Institute). Therefore, we need to do everything within reason to reduce risk.

In a meta-analysis (a group of eight prospective or forward-looking studies), results show that women who were in the second to fifth quintile blood levels of carotenoids, such as alpha-carotene, beta-carotene, and lutein and zeaxanthin, had significantly reduced risk of developing breast cancer (J Natl Cancer Inst 2012;104(24):1905-1916).

Thus, there was an inverse relationship between carotenoid levels and breast cancer risk. Even modest amounts of carotenoids can have a resounding effect in potentially preventing breast cancer.

ALS: Lou Gehrig’s disease

ALS is a disabling and feared disease. Unfortunately, there are no effective treatments for reversing this disease. Therefore, we need to work double time in trying to prevent its occurrence.

In a meta-analysis of five prestigious observational studies, including The Nurses’ Health Study and the Health Professionals Follow-Up Study, results showed that people with the greatest amount of carotenoids in their blood from foods such as spinach, kale and carrots had a decreased risk of developing ALS and/or delaying the onset of the disease (ANN NEUROL 2013;73:236–245). This study involved over 1 million people with more than 1,000 who developed ALS.

Those who were in the highest carotenoid level quintile had a 25 percent reduction in risk, compared to those in the lowest quintile. This difference was even greater for those who had high carotenoid levels and did not smoke, achieving a 35 percent reduction. According to the authors, the beneficial effects may be due to antioxidant activity and more efficient function of the power source of the cell: the mitochondrion. This is a good way to prevent a horrible disease while improving your overall health.

Positive effects of healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are several obstacles to healthy eating. Two critical factors are presentation and perception.

Presentation is glorious for traditional dishes, like turkey, gravy and stuffing with lots of butter and creamy sauces. However, vegetables are usually prepared in either an unappetizing way — steamed to the point of no return, so they cannot compete with the main course — or smothered in cheese, negating their benefits, but clearing our consciences.

Many consider Thanksgiving a time to indulge and not think about the repercussions. Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. Why is it so important to change our mindsets? Believe or not, there are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when most gain the predominant amount of weight for the entire year. However, according to a study published in The New England Journal of Medicine on March 23, 2000, people do not lose the weight they gain during this time. If you can fend off weight gain during the holidays, just think of the possibilities for the rest of the year.

Also, if you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (www.heart.org). However, with a little Thanksgiving planning, you can reap significant benefits. What strategies should you employ for the best outcomes?

• Make healthy, plant-based dishes part of the main course. I am not suggesting that you forgo signature dishes, but add to tradition by making mouthwatering vegetable-based dishes for the holiday.
• Improve the presentation of vegetable dishes. Most people don’t like grilled chicken without any seasoning. Why should vegetables be different? In my family, we make sauces for vegetables, like a peanut sauce using mostly rice vinegar and infusing a teaspoon of toasted sesame oil. Good resources for appealing dishes can be found at www.pcrm.org, EatingWell magazine, www.wholefoodsmarket.com and many other resources.
• Replace refined grains with whole grains. A study in the American Journal of Clinical Nutrition on Sept. 29, 2010, showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (Am J Clin Nutr 2010 Nov;92(5):1165-71). Not only did participants lose subcutaneous fat found just below the skin, but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer.
• Create a healthy environment. Instead of putting out creamy dips, processed crackers and candies as snacks prior to the meal, put out whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.
• Offer more healthy dessert options, like pumpkin pudding and fruit salad.

The goal should be to increase your nutrient-dense foods and decrease your empty-calorie ones.

You don’t have to be perfect, but improvements during this time period have a tremendous impact — they set the tone for the new year and put you on a path to success. Why not turn this holiday into an opportunity to de-stress, rest, and reverse and/or prevent chronic disease by consuming plenty of carotenoid-containing foods.

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 and/or consult your personal physician.

We need cholesterol for our cells to function properly, but when we have too much it can have deleterious effects on our hearts. We know that higher LDL “bad” levels and total cholesterol levels may be dangerous and that higher HDL cholesterol levels are good. I am not telling you anything new. However, new guidelines for cholesterol were just released through a joint effort by the American Heart Association and American College of Cardiology (J Am Coll Cardiol. 2013, online Nov. 15; Circulation. 2013, online Nov. 12).

The new guidelines call into question the targets physicians have been using to treat patients with elevated LDL levels. We had been treating patients to a target LDL of either <100 mg/dl or <70 mg/dl, depending on the patient’s status. Instead of focusing on cholesterol targets, these new guidelines suggest that physicians use a risk calculator to assess a patient’s chance of having a cardiovascular event, such as a stroke or a heart attack, except when LDL >190 mg/dl. For these patients, you treat based on the high number.

There are four groups that should be treated, according to the new guidelines. In the most debatable category, healthy patients with a calculated 10-year cardiovascular risk of >7.5% should receive moderate- to high-intensity treatment with cholesterol-lowering medications, such as statins. In patients with cardiovascular disease, higher levels of medication should be used to reduce LDL by 50% or more.

The idea is to treat the patient overall, not to aim for a specific target. To this end, the guidelines suggest that, once statins are prescribed, LDL levels should not be monitored on a regular basis. Without monitoring, though, how will you know whether the treatment is having an effect?

One of the study authors gives an example: if a patient is on cholesterol-lowering medication and is following appropriate lifestyle modifications, but has an LDL that is slightly above the goal, then treatment should not be intensified (medpagetoday.com). The guidelines help to prevent the use of nonstatin drugs that reduce levels of LDL, but that have not shown clinical benefit.

The guidelines also suggest that someone who only has mildly elevated cholesterol levels and no other risk factors, including age, does not warrant medication. This sounds reasonable so far, right? Unfortunately, it is not as clear-cut as it sounds. This approach dramatically changes the paradigm in which physicians have been operating for years.

Medical community reactions

Cholesterol — whether to treat and when — suddenly has become a highly controversial issue. There are two camps within the medical community: one believes these guidelines will help define the patients who are prime subjects to be treated either for primary prevention (prior to a cardiovascular episode) and secondary prevention (those who have had cardiovascular events); the other worries this may result in overtreatment.

The risk factors in the new calculator include age, sex, systolic blood pressure, total cholesterol levels, LDL levels, smoking status, high blood pressure treatment and diabetic status. This seems simple enough, but like most things in medicine, whenever something is significantly overhauled, there are potential problems. I have to be forthright and say after reading the commentary, I am leaning toward the camp that is skeptical of the guidelines. Let’s look at the potential problems.

Potential overuse of statins

The cardiovascular risk of >7.5% for treatment is significantly lower than what it has been in the past, 10% to 20%. According to an editorial written in a prominent journal, two physicians calculate that it may increase the number of healthy patients treated with statins by 70%. They point out that statins are ineffective in death reduction if cardiovascular risk is less than 20% (BMJ. 2013;347:f6123). Also they note that it takes 140 patients treated with statins to prevent one heart attack or stroke.

In addition, using the calculator, someone can have normal cholesterol levels and be put on statins based on other factors, such as age, race and sex. Therefore, many more patients could be treated with medications, most likely statins, than in the past.

Flawed calculator

In a New York Times article published Nov. 18, entitled “Flawed Gauge for Cholesterol Risk Poses a New Challenge for Cardiologists,” the authors note that the online calculator may overestimate the risk percentages. Paul Ridker, M.D., and Nancy Cook, M.D., both Harvard Medical School physicians, tested the calculator by using large trials, such as the Women’s Health Initiative Observational Study, determining that risk is inflated by a mean of 100%. This is because the calculator’s design is based on studies that are over a decade old, many of them from the 1990s.

Demographics have changed since then: we have fewer smokers; heart attack and stroke risk has become similar in men and women, whereas men were at higher risk in the past; and cardiovascular disease incidence has decreased. The calculator also assumes that risk moves in a linear fashion, so as the blood pressure is elevated, risk increases in direct proportion, but it is not that simple.

Statin dosing

The suggested treatment with statins is moderate or high intensity. The problem with this approach is that the higher the intensity, the greater the risk of side effects, such as increased risk of diabetes (Arch Intern Med. 2012;172:144-152), fatigue (Arch Intern Med. 2012;172:1180-1182), muscle cramps and pain (Pharmacotherapy. 2010;30:541-553), as well as cataracts (Optom Vis Sci. 2012;89:1165-1171). The FDA recently warned about using high statin doses and muscle pain (fda.gov).

Lifestyle and anthropometrics

The risk calculator does not incorporate lifestyle, whether positive or negative, or anthropometrics, such as waist circumference and BMI.

To boot, there are no clinical trials that show the risk calculator is beneficial. It has never been examined in this way, and there have been no new trials that require altering the guidelines in this way.

Guidelines, of course, are just that; they are at the discretion of the physician to follow and discuss with the patient, but ultimately treatment decisions should be made by the patient and physician in partnership. To their credit, the authors of the guidelines acknowledge this very same point.

If you do take statins, don’t become complacent about lifestyle changes — nutrient dense diet, exercise, stress management and quit smoking — and think statins are a silver bullet. On the positive side, giving statins for risk reduction may be more beneficial than just lowering cholesterol numbers. Also, the new guidelines may make physicians hesitant to give drugs that just lower numbers, but that have never shown any clinical benefit.

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 and/or consult your personal physician.

We all need fat in our diets, but what fats do we really need and what can we do without? There are several types of fats that have differing impacts on our health, including trans fats, saturated and unsaturated fats.

Trans fats are fats that we can definitely do without. The Food and Drug Administration has taken one of its most aggressive stances in years regarding trans fats. The agency announced recently they are in the preliminary stages of potentially banning artificial trans fats, based on findings from expert panels and scientific studies.

Trans fats are found in processed foods, baked goods and fried foods, as well as margarine, frozen pizzas, coffee creamers and microwave popcorn. To determine whether a food has trans fats, check the label for partially hydrogenated oils. Some restaurants may also use trans fats.

Why is the FDA’s potential banning of trans fats important? According to the agency, just by eliminating this one type of fat, it could reduce annual incidences of heart attacks by 20,000 and deaths due to heart disease by 7,000 (federalregister.gov). The Institute of Medicine’s position is that there is no benefit to trans fats, only potential harm from consuming any amount.

However, it is still unclear how far the FDA will go to eliminate trans fats. Will they force food manufacturers to eliminate trans fats if they are less than 0.5 g per serving? Products with low levels per serving, such as Skippy peanut butter, are allowed to say they are free of trans fats. There are some foods that contain small amounts of natural trans fats, but not the ones mentioned above.

Does this mean that bakery goods and fast foods are going to be healthy for us? Hardly! Many food establishment have already eliminated trans fats. We consume significantly less than we once did. In 2003, we consumed 4.6 g per day, but in 2012, we consumed 1 gram daily, according to the FDA. However, consuming any trans fats may be too much.

Mayor Bloomberg may be remembered for his impact on dietary composition. In a study, trans fat consumption decreased dramatically in fast food establishments throughout NYC in just two years from 2007 to 2009 (Ann Intern Med. 2012;157:81-86). And the amount of products purchased from these establishments that were trans fat-free increased dramatically.

Trans fats and stroke

In the Women’s Health Initiative Observation Study, trans fats were associated with an approximate 40% increased risk of ischemic (clot-based) strokes in postmenopausal women in the highest consumption quintile compared to the lowest (Ann Neurol. 2012 Nov.;72:704-715). Ischemic strokes are by far the most common type of stroke. There were over 87,000 women in this study between the ages of 50 and 79. Interestingly, aspirin seemed to help prevent the strokes in this population. Many of us are on the fence about taking aspirin, but this may a reason for postmenopausal women to discuss aspirin with their physicians. Though, if the FDA does ban trans fats, aspirin may not be needed.

Trans fats and aggression

Psychological changes are another concern. In a recent study with 945 men and women, results showed that the more trans fats consumed, the greater the probability of irritability, aggression and impatience (PLoS ONE 7:e32175). This may be an indication that diet plays a role in mood changes and disorders.

Saturated fats and cognitive impact

What if we ate more saturated fats? In the observational Women’s Health Study, results for 6,000 postmenopausal women showed that those who consumed the most saturated fat had a significant decline in global memory and verbal memory scores, compared to those who consumed the least.

The good news is that those who consumed the highest amounts of monounsaturated fats had an improvement in these scores, compared to those who consumed the least (Ann Neurol. 2012 July;72:124-134). Researchers concluded that the amounts of specific fat types were more important than the overall amount of fat consumed.

There are better fats, such as monounsaturated and polyunsaturated fats, and there are fats that are worse for us, such as saturated fats. However, some foods contain both saturated and unsaturated fats, and this is where those critical of calling saturated fat “bad” tend to utilize examples. With the right balance of unsaturated to saturated fats, certain foods can be beneficial, like nuts, olive oil and avocado – in moderation, of course.

In a randomized controlled trial, considered the gold standard of studies, type 2 diabetes patients who received mixed nuts saw a decrease in their HbA1C (a three-month measure of glucose or sugar levels) and a decrease in their LDL “bad” cholesterol (Diabetes Care. 2011;34:1706-1711).

Those who consumed muffins instead of nuts or who consumed half nuts and half muffins saw no improvement in their HbA1C or LDL levels. The takeaway is that a small handful of nuts, about 2 ounces daily in place of carbohydrates, can have a significantly positive impact on the health of type 2 diabetes patients.

Unsaturated fat impact

In a randomized controlled study comparing a Mediterranean diet to a low-fat diet, those on MEDI showed a significant 30% decrease in the risk of cardiovascular disease and related death (N Engl J Med. 2013;368:1279-1290). However, those in the low-fat group could not maintain low-fat levels, thus they consumed a diet similar to the standard American diet, and those in the MEDI group consumed more vegetables, olive oil and/or nuts than is typical.

It also speaks to the fact that it is not enough to reduce fat; it’s important to replace it with the right things. If you eat pasta and grains instead, this may not alter results; however, if you replace high levels of fat with nutrient-dense vegetables, then the effects, as seen in the MEDI, tend to be very favorable.

I applaud the FDA for considering banning artificial trans fats, but be forewarned that you need to be wary of partially hydrogenated oils on labels, even if the product says “trans fat-free.” Saturated fats by themselves may be unhealthy as well. However, saturated fats in combination with unsaturated fats may promote positive effects on your overall health. Regardless, moderation is important when it comes to fats, even with good fats. Too much is bad, no matter what the source.

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 and/or consult your personal physician.