What causes type 2 diabetes? It would seem like an obvious answer: obesity, right?

Well, obesity is a contributing factor, but not necessarily the only factor. This is important, because diabetes prevalence is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 8 percent of the U.S. population has type 2 diabetes. For those 65 and older, the prevalence is considerably higher, at 26.9 percent (https://diabetes.niddk.nih.gov).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars, because form is important. Sugar and fruit are not the same with respect to their effect on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when comes to its effect on diabetes’ prevalence. In an epidemiological (population-based) study published in the journal PLoS One in February, the results show that sugar may increase the prevalence of type 2 diabetes by 1.1 percent worldwide (PLoS One. 2013;8(2):e57873). This seems like a small percentage, however, we are talking about the overall prevalence, which is around 8 percent in the U.S., as noted in the introduction.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12 ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to New York City Mayor Michael Bloomberg’s drive to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

The effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (Nutr J. published online March 5, 2013). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a BMI of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels.

It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have type 2 diabetes (Am J Lifestyle Med. 2013;7(1):23-26).

Cinnamon may work much the same way as some medications used to treat type 2 diabetes, such as GLP-1 agonists. In a study with healthy volunteers, cinnamon raised the level of GLP-1 (Am J Clin Nutr. 2007;85:1552–1556). Also, in a RCT with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (J Am Board Fam Med. 2009;22:507–512). The data is far too preliminary to make any comparison with FDA-approved medications. However it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (Diabetologia online March 1, 2013).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with my Jan. 31 article on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

Thus, diabetes is mostly likely a disease caused by a multitude of factors, including obesity, sedentary lifestyle and visceral fat. The good news is that many of these factors are modifiable. Cinnamon and fruit seem to be two factors that help decrease this risk, as does exercise, of course.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make at least some lifestyle modifications. So America, take an active role and get off your butt.

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 www.medicalcompassmd.com and/or consult your personal physician.

I just realized that February is American Heart Disease Awareness Month. My wife pointed out that this is also International Typewriter Appreciation Month, whatever that means. When was the last time that you used a typewriter? Therefore, I thought that my last article for the month of February should focus on this most prevalent disease and the dangers of calcium in increasing the risk of heart attacks and all-cause mortality.

I wrote about a very similar topic on April 26, 2011. First, let me summarize what we knew then. At that time, a study called the Women’s Health Initiative showed that calcium supplements may cause a 20 percent rise in the risk of heart attack (BMJ. 2011 April 19;342:d2040). There were 17,000 women involved in this study with calcium. The participants who saw this modest rise in risk were taking 1000 mg of calcium supplementation. In the same paper, there was also a meta-analysis (group of three studies) that showed increases of 20 percent in both heart attacks and strokes with calcium. It did not matter whether participants were taking vitamin D or not. At the time, I hedged my bets by saying it was only one paper. The results were intriguing, though — the risk of a heart attack surpassed the benefits of reducing fracture.

Recently, several large studies reinforced the negative effects of calcium as related to the heart, and the impact seems to be even greater. Let’s examine these studies and their implications in more detail.

Calcium’s impact on women

In the Swedish Mammography Cohort, published in the same medical journal as the aforementioned study, the results showed an almost 50 percent increased risk of cardiovascular disease deaths in women who consumed more than 1400 mg of calcium from their diet, which included calcium supplements, compared to those who consumed 600 to 1000 mg (BMJ. 2013 Feb. 13;346:f228). Cardiovascular disease risk in this study included heart disease and stroke combined. The participants who consumed less than 600 mg of calcium also had an increase in mortality, but not nearly as significant as the high calcium intake group.

When you break down the percentages, the data are even more interesting. In this study, heart disease deaths increased by 114 percent. However, unlike the previous study, there was no significant increase in stroke deaths.

All-cause mortality, which means from any source, not just cardiovascular, was increased by 40 percent. Also, those women in the high calcium group had a two-and-a-half times greater risk of all-cause death when they were taking calcium supplements, while those in the same group who were not taking supplements had a much less significant (17 percent) increased risk.

Not to worry. As the authors point out, those who consume calcium without supplements are most likely to be in the ideal range. This was a large observational prospective (forward-looking) study involving over 60,000 women. The duration of the study was 19 years. However, a weakness of the study is that the overall event rate was small. The authors’ conclusion was that women should avoid calcium supplementation and get their calcium from dietary sources.

Calcium’s impact on men

Not to be left out, men also seem to be negatively affected by high calcium. The National Institutes of Health-AARP Diet and Health Study, published a week earlier than the women’s study mentioned above, showed that there was a 20 percent increased risk of cardiovascular disease death in those men who took at least 1000 mg of calcium on a daily basis compared to those who did not (JAMA Intern Med. Online Feb. 4). Again, the predominant effect was seen with death from heart disease. This was a prospective study, involving 388,000 men and women who were followed for over 12 years.

To make the data slightly more obtuse, this effect was only seen in men, not in the women involved in the study. The authors cannot explain why there was this difference in gender. However, when the data was analyzed further, and multivitamins were eliminated from the equation as a contributing source of calcium, those men taking calcium supplements of at least 1000 mg were even more likely to suffer heart disease deaths, with a 37 percent increased risk.

In my own practice, having seen several hundred patients in the last few years, it seems none of them have been deficient in calcium. Yet when many patients come for an initial visit, they are taking varying amounts of calcium supplements. One of the first things I usually do is either reduce or discontinue the dose. I then follow up with a laboratory test to make sure they are not deficient after changing their supplements.

I also educate them about foods that are good sources of calcium and explain why. Believe it or not, we absorb calcium best from plant-based sources in our diet, such as kale, almonds, tofu and unhulled sesame seeds. In an article entitled, “Do calcium supplements increase cardiovascular mortality?“ published on Feb. 21, the author, after reviewing much of the pertinent data, suggests that calcium-rich foods are the wisest and safest of choices, rather than supplementation (www.medscape.com).

Finally, in the EPIC trial, there was a decrease in the risk of a heart attack from dietary calcium (Heart. 2012; 98(12):920-925). Unfortunately, there was no effect, beneficial or not, on the number of deaths from all-cause mortality or cardiovascular disease. However, there was a noticeable 139 percent increased risk of heart attacks in calcium supplement users.

Therefore, the best way to avoid this conundrum of making sure your bones are strong and getting enough calcium, while not increasing your risk of mortality is to do several things. Make sure your vitamin D levels are sufficient, for vitamin D helps with the absorption of calcium into the bones. Most people are deficient or insufficient (a milder form) in vitamin D, so if you want to take a supplement, start here. The other is to have a well-balanced diet that includes calcium-rich foods, ensuring you are in the optimal range of daily intake and getting very little or no calcium from supplements. Lastly, don’t begin using calcium supplements before consulting with your physician.

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 have inflammation in our bodies, inflammation that is a potential underlying cause for a great number of diseases. Can we demonstrate the level of inflammation by measuring it? The answer is yes, otherwise I would not be writing this article.

One of the most widely studied biomarkers for inflammation is high-sensitivity C-reactive protein (hsCRP), also referred to as CRP. High-sensitivity means that we can measure levels as low as 0.3 mg/L more accurately.

What is the significance of the different levels? In heart disease, individuals who have levels less than 1.0 mg/L are in the optimal range for low risk of inflammation. Levels of 1-3 mg/L is the average risk range and greater than 3.0 mg/L is the higher risk profile. Above 10.0 mg/L is less specific to heart disease, although still related, but more likely associated with other causes, such as infection and autoimmune diseases (uptodate.com; Diabetes Technol Ther. 2006;8(1):28-36). This biomarker is derived from the liver.

The downside to CRP is that it is not specific to heart disease, nor definitive for the risk of the disease. The upside though is that it may be helpful with risk stratification, which helps us understand where we sit on a risk spectrum, and with progression in other diseases, such as age-related macular degeneration, diabetic retinopathy, depression and autoimmune diseases.

Let’s look at the evidence.

Age-related macular degeneration (AMD)

AMD is the leading cause of blindness in patients over the age of 65 (Prog Retin Eye Res. 2007 Nov;26(6):649-673). Therefore, it is very important to help define risk stratification for this disease. In a prospective study, the results showed that hsCRP levels were inversely associated with the risk of developing AMD. The group with an hsCRP more than 3.0 mg/L had a 50 percent increased risk of developing overall AMD compared to the optimal group with less than 1.0 mg/L. But even more interestingly, the risk of developing neovascular or wet AMD increased to 89 percent in this high-risk group.

The significance of wet AMD is that it is one type of advanced-stage AMD that results in blindness. This study involved five studies where the researchers thawed baseline blood samples from middle-aged participants who had hsCRP levels measured. There were more than 2,000 participants with a follow-up as long as 20 years. According to the study’s authors, annual eye exams and lifestyle modifications, including supplements, may be able to stem this risk by reducing hsCRP.

These results reinforce those of a previous prospective study that showed that elevated hsCRP increased the risk of AMD by threefold (Arch Ophthalmol. 2007;125(3):300-305). This study utilized data from the Women’s Health Study, which involved over 27,000 participants. Like the study mentioned above, this one also defrosted blood samples from baseline and looked at follow-up incidence of developing AMD in initially healthy women.

The highest group had hsCRP levels over 5.2 mg/L. Additionally, when analyzing similar cutoffs for high- and low-level hsCRP, as the above trial used, those with hsCRP over 3.0 had an 82 percent increased risk of AMD compared to those with an hsCRP of less than 1.0 mg/L.

Diabetic retinopathy —
a complication of diabetes

We know that diabetes affects significantly more than 10 percent of the population and is continuing to rise at a rapid rate. One of the complications of diabetes affects the retina (back of the eye) and is called diabetic retinopathy. This is a leading cause of vision loss (Am J Ophthalmol. 2003;136(1):122-135). One of the reasons for the vision loss is macular edema, or swelling, usually due to rupture of tiny blood vessels below the macula, a portion of the back of the eye responsible for central vision.

The DCCT trial, a prospective study involving over 1,400 type-1 diabetes patients, showed an 83 percent increased risk of developing clinically significant macular edema in the group with the highest hsCRP levels compared to those with the lowest (JAMA Ophthalmol. 2013 Feb 7;131:1-8). Although these results were with type-1 diabetes, patients with type-2 diabetes are at equal risk of diabetic retinopathy if glucose levels or sugars are not well-controlled.

Depression

Depression is a very difficult disease to control and is a tremendous cause of disability. If we can minimize the risk of complications and hospitalizations, this is probably the most effective approach.

Well, it turns out that inflammation is associated with depression. Specifically, in a recent prospective observational trial, rising levels of CRP had a linear relationship with increased risk of hospitalization due to psychological distress and depression (JAMA Psychiatry. 2013;70(2):176-184).

In other words, compared to levels of less than 1 mg/L, those who were 1 to 3 mg/L, 3 to 10 mg/L and greater than 10 mg/L, had increased risk from 30 percent to 84 percent to 127 percent, respectively. This study involved over 70,000 patients.

What can be done to reduce
inflammation?

This is the key question, since we now know that hsCRP is associated with systemic inflammation. In the Nurses’ Health Study, a very large, prospective observational study, the DASH diet decreased the risk of both heart disease and stroke, which is impressive. But for this article, in regards to hsCRP, the DASH diet decreased the levels significantly, which also was associated with a decrease in clinically meaningful endpoints of stroke and heart disease (Arch Intern Med. 2008;168(7):713-720).

The DASH diet is nutrient-dense with an emphasis on fruits, vegetables, nuts, seeds, legumes and whole grains and de-emphasis on processed foods, red meats, sodium and sweet beverages.

Conclusion

As the evidence shows with multiple diseases, hsCRP is a very valuable nonspecific biomarker for inflammation in the body.

To stem the effects of inflammation, reducing hsCRP through lifestyle modifications and drug therapy may be a productive way of reducing risk, slowing progression and even potentially reversing some disease processes.

The DASH diet is a very powerful approach to achieving optimal levels of hsCRP without incurring potential side effects. This is a call to arms to have your levels measured, especially if you are at high risk or have chronic diseases such as heart disease, diabetes, depression and autoimmune diseases. HsCRP is a simple blood test with easy-to-obtain results.

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.

Valentine’s Day is one of the wonderful things about winter. For many, it lifts the mood and spirit. A traditional gift is chocolate. But do the benefits of chocolate go beyond Valentine’s Day? The short answer is yes, which is good news for chocolate lovers. However, we are not talking about filled chocolates, but primarily dark chocolate and cocoa powder.

The health benefits of chocolate are derived in large part from its flavonoid content — compounds that are produced by plants. These health benefits are seen in cardiovascular disease, including stroke, heart disease and blood pressure. This is ironic, since many chocolate boxes are shaped as hearts. Unfortunately, it is not necessarily the chocolates that come in these boxes that are beneficial.

Let’s look at the evidence.

Effect on heart failure

Heart failure is very difficult to reverse. Therefore, the best approach is prevention, and dark chocolate may be one weapon in this crusade. In the Swedish Mammography Cohort study, those women who consumed dark chocolate saw a reduction in heart failure (Circ Heart Fail. 2010;3(5):612-6). The results were on a dose response curve, but only to a point. Those women who consumed two to three servings of dark chocolate a month had a 26 percent reduction in the risk of heart failure.

For the dark chocolate lovers, it gets even better. Women who consumed one to two servings per week had an even greater reduction of 32 percent. However, those who ate more than these amounts actually lost the benefit in heart failure reduction and may have increased risk. With a serving (1 ounce) a day, there was actually a 23 percent increased risk.

This study was a prospective (forward-looking) observational study that involved more than 30,000 women over a long duration, nine years. The authors comment that chocolate has a downside of too much fat and calories and, if eaten in large quantities, it may interfere with eating other beneficial foods, such as fruits and vegetables. The positive effects are most likely from the flavonols, a subset of flavonoids, which come from the cocoa solids — the chocolate minus the cocoa butter.

Impact on mortality from heart attacks

In a two-year observational study, results showed that chocolate seemed to reduce the risk of cardiac death after a first heart attack (J Intern Med. 2009;266(3):248-57). Again, the effects were based on a dose-response curve, but unlike the previous study, there was no increased risk beyond a certain modest frequency.

Those who consumed chocolate up to once a week saw a 44 percent reduction in risk of death, and those who ate the most chocolate — two or more times per week — saw the most effect, with 66 percent reduced risk. And finally, even those who consumed one serving of chocolate less than once per month saw a 27 percent reduction in death, compared to those who consumed no chocolate.

The study did not mention dark or milk chocolate, however this was another study that took place in Sweden. In Sweden, their milk chocolate has substantially more cocoa solids, and thus flavonols, than that manufactured for the U.S. There were over 1,100 patients involved in this study, and none of them had a history of diabetes, which is important to emphasize.

Stroke reduction

I don’t know anyone who does not want to reduce the risk of stroke. We tell patients to avoid sodium in order to control blood pressure and reduce their risk. Initially, sodium reduction is a difficult thing to acclimate to — and one that people fear. However, it turns out that eating chocolate may reduce the risk of stroke, so this is something you can use to balance out the lifestyle changes.

In yet another study, the Cohort of Swedish Men, which involved over 37,000 men, there was an inverse relationship between chocolate consumption in men and the risk of stroke (Neurology. 2012;79:1223-1229).Those who ate at least two servings of chocolate a week benefited the most with a 17 percent reduction in both major types of stroke — ischemic and hemorrhagic — compared to those who consumed the least amount chocolate. Although the reduction does not sound tremendous, aspirin reduces stroke risk by 20 percent. However, this study was observational, not the gold-standard randomized controlled trial, like the aspirin studies.

Blood pressure

One of the most common maladies, especially in people over 50, is high blood pressure. So, whatever we can do to lower blood pressure levels is important, including decreasing sodium levels, exercising and even eating flavonoid-rich cocoa.

In a meta-analysis (a group of 20 RCTs), flavonoid-rich cocoa reduced both systolic (top number) and diastolic (bottom number) blood pressure significantly: -2.77 mm Hg and -2.20 mm Hg, respectively (Cochrane Database Syst Rev. 2012:15;8:CD008893).These studies involved healthy participants, who are sometimes the most difficult in which to show a significant reduction, since their blood pressure is not high initially. One of the weaknesses of this meta-analysis is that the trials were short, between two and 18 weeks.

Why chocolate has an effect

Chocolate has compounds called flavonoids. The darker the chocolate, the more flavonoids there are. These flavonoids have potential antioxidant, antiplatelet and anti-inflammatory effects.

In a small randomized controlled trial comparing 22 heart transplant patients, those who received dark flavonoid-rich chocolate, compared to a cocoa-free control group, had greater vasodilation (enlargement) of coronary arteries two hours after consumption (Circulation. 2007 Nov 20;116(21):2376-82). There was also a decrease in the aggregation, or adhesion, of platelets, one of the primary substances in forming clots. The authors concluded that dark chocolate may also cause a reduction in oxidative stress.

It’s great that chocolate, mainly dark, and cocoa powder have such substantial effects in cardiovascular disease. However, certain patients should avoid chocolate such as those with reflux disease, allergies to chocolate and diabetes. Be aware that Dutch-processed, or alkalized, cocoa powder may have lower flavonoid levels and is best avoided. Also, the darker the chocolate is, the higher the flavonoid levels. I suggest that the chocolate be at least 60 to 70 percent dark.

Moderation is the key, for all chocolate contains a lot of calories and fat. Based on the studies, two servings a week are probably where you will see the most cardiovascular benefits. Happy Valentine’s Day!

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.

In a study published on Jan. 31 in the New England Journal of Medicine, researchers investigate the myths, facts and assumptions associated with losing weight in obese patients (N Engl J Med. 2013;368:446-454). This study has deservedly received a substantial amount of attention, both in the medical news and the layman’s press, such as The New York Times.

The authors brought up really good points, but — and this is the keyword: but — are their conclusions obfuscated or confusing?

Let’s address some of the specific points in the study and the perspective from which they are made. Following are some of the assumptions that they examine.

Adding fruits and vegetables to the diet results in weight loss

The authors highlight that this statement is inconclusive. That while fruits and vegetables may be good for your health, they don’t help with weight loss.

But you have to analyze this statement more closely. They are not saying that fruits and vegetables don’t help with weight loss. They say that adding them is not helpful. I agree that if you add these items to a diet of cheeseburgers and fries, you are certainly not going to lose weight.

However, if you shift your diet to one that involves a vegetable-rich, plant-based approach, this has a much different effect than just adding fruits and vegetables without making any other changes. There are a number of studies showing significant long-term weight loss with this type of diet. For instance, in a small, retrospective study, patients on a plant-based, nutrient-dense diet involving a significant amount of fruits and vegetables, lost an average of 33 pounds in the first year and 59 pounds in the second year (Altern Ther Health Med. 2008;14:48-53). Granted, this is not the best-designed study, but it suggests that vegetable-rich diets are effective for significant and sustained weight loss.

Slow, gradual weight loss is best for long-term success

The authors debunk this as a myth. However, what do they mean by this statement? Using a meta-analysis, the results show that ultra-low calorie diets are more effective for losing weight than a slow, gradual approach (Int J Behav Med. 2010;17:161-167). This all seems to make sense.

But, the authors compare weight loss of 16 percent to 10 percent over six months. While this may be statistically significant, it is not necessarily clinically rapid versus slow weight loss. For instance, a 200-pound obese patient who loses 16 percent of her weight has lost only 12 pounds more than someone who loses 10 percent of her weight in six months. This is roughly two extra pounds a month.

A diet primarily focused on severe calorie restriction, rather than nutrient density, may work for the short term, but it may throw the homeostasis of the body’s hunger-inducing hormones, such as ghrelin and leptin, into disarray. This creates an environment that may actually cause weight to be regained in the long term (N Engl J Med. 2011; 365:1597-1604).

Another thing to consider is that a low-calorie diet may not necessarily increase life span, as we once thought. This was demonstrated in a study using rhesus monkeys (Nature online Aug. 29). In my Sept. 13, 2012 article, entitled “Calorie restriction disappoints in longevity and quality of life,” I addressed that fact that there may be better ways to lose weight than calorie restriction. One option is the DASH diet, which reduces the risk of heart disease and other chronic diseases (Arch Intern Med. 2008;168:713-720).

Bariatric surgery is valuable for some patients for long-term weight loss

The authors conclude that this may be true, and they support their statement with a prospective trial (N Engl J Med. 2004;351:2683-2693). I agree that it may be appropriate for some patients.

But, what is not mentioned is that at least 50 percent of patients who have bariatric surgery tend to regain weight within 24 months, so that the original BMI change is no longer significant (Obes Surg. 2008 Jun;18(6):648-651). There are also significant side effects for some patients who undergo bariatric surgery, such as the dumping syndrome, which can occur especially with high levels of simple carbohydrates in as many as 50 percent of patients, and the inability to properly absorb nutrients, such as B12, calcium, iron and folate (Surgery. 1960;48:185-194; Obes Surg. 2005;15(2):145-154).

Weight-loss pills and prepackaged meals may be effective tools

According to the author, weight-loss pills and packaged meals may be the best options for weight loss.

But, the history of weight-loss pills is tarnished. So many of them have been pulled off the market after being approved, because of untoward side effects. Also, once patients discontinue the drugs, they appear to regain the lost weight.

I don’t disagree that diets providing packaged meals are effective ways to lose weight.

But, just like with drug therapy, once patients discontinue the meals, they tend to regain weight. Just like the old saying, it is better to teach a man to fish than to provide the fish for him.

Is this study potentially biased?

There may be some bias involved as well, since the authors are not without conflicts of interest. Most of them are associated with pharmaceutical companies as paid speakers, or they consult as well as associate with food manufacturers and prepackaged meal providers. It is true that disclosing this information is important, but take note when reading any study of the authors’ affiliations — they tend to color their perspectives.

Benefit of small energy changes

Small, sustained changes in energy-intake or expenditure will produce large, long-term weight changes.

The authors conclude that this is a myth. I emphatically disagree. In fact, last week I wrote about the positive effects of exercise on weight loss. Those that lost the most weight and sustained that loss not only did moderate activities, about 30 minutes a day, four to five times per week, but also were less sedentary the rest of day, as demonstrated by a pedometer (Am J Prev Med. 2012;43(6):629-635).

The authors do bring to light some very pertinent points. They address some other assumptions that really are not based on any scientific evidence. I would encourage people to read the article in its entirety.

But know that not all of the points have been flushed out completely, and keep in mind that the authors have their distinct perspectives and quite a few conflicts of interest.

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.

When we make our New Year’s resolutions to exercise regularly, the goal for many is to change body composition, to lose weight or at least to maintain weight, but is this reality or myth?

It is a hotly debated topic. You would think the answer would straightforward, since exercise helps us prevent and resolve a great many diseases. For example, in last week’s article, I wrote about the value of exercise before the flu shot in improving immunity.

At the same time, we hope exercise impacts our weight. Does it? This is something that we should know, and rightfully so, before we start exercising. It is important to manage our expectations. There are some new and intriguing studies that address whether exercise has an impact on weight management. The short answer is yes, however, not always in ways we might expect.

Then the questions become: what type of exercise should we be doing, how frequently and for how long? Let’s look at the evidence.

Duration

It makes sense that the more we exercise to lose weight, the better, or at least that is what we thought. In a recent small randomized controlled trial (RCT), the gold standard of studies, the results showed that the moderate group in terms of duration saw the most benefit for weight loss (Am J Physiol Regul Integr Comp Physiol. 2012 Sep 15;303(6):R571-R579). There were three groups in the study — a sedentary group (low), a group that did 30 minutes per day of aerobic exercise (moderate) and a group that did 60 minutes per day of aerobic exercise (high).

Perhaps obviously, the sedentary group did not see a change in weight. Surprisingly, though, the group that did 30 minutes of exercise per day experienced not only significantly more weight loss than the sedentary group, but also more than the 60-minute exercise group. The aerobic exercises involved biking, jogging or other perspiring activities. These were healthy young men that were overweight, but not obese, and the study duration was three months.

The authors surmise that the reason for these results is that the moderate group may have garnered more energy and moved around more during the remainder of the day, as sensors showed. The highest exercise group was sedentary through most of the rest of day, probably due to fatigue. Also, it seemed that the highest exercise group ate more than the moderate group, though the difference was not statistically significant. While this study is of impressive quality, it is small and of short duration. Nonetheless, its results are encouraging.

Postmenopausal women

As a group, postmenopausal women have considerable difficulty losing weight and maintaining weight loss. In a secondary analysis of a RCT, there were three aerobic exercise groups differentiated by the number of kcal/kg per week they burned: 4, 8 and 12 (Am J Prev Med. 2012;43(6):629-635). All of the groups saw significant reductions in waist circumference. Interestingly, however, a greater number of steps per day outside of the training, measured by pedometer, were primarily responsible for improved waistline circumference, regardless of the intensity of the workouts.

But it gets more intriguing because the group that exercised with the lowest intensity was the only one to see significant weight loss. More is not always better, and in the case of exercise for weight loss, less may be more. This study reinforces the suppositions made by the authors of the previous men’s study: exercise to a point where it is energy inducing and not beyond.

Premenopausal women

Not to ignore younger women, those who were premenopausal also saw a significant benefit with weight maintenance and exercise after having intentionally lost weight.

In a prospective (forward-looking) study, young women who did at least 30 minutes of exercise four to five days per week were significantly less likely to regain weight that they had lost, compared to those who were sedentary after losing weight (Obesity 2010;18(1):167-174).

Some of the strengths of this study were its substantially long six-year follow-up period and its large size, involving over 4,000 women between the ages of 26 and 45. Running and jogging were more impactful in preventing weight gain than walking with alacrity. However, all forms of exercise were superior to the sedentary group.

Aerobic exercise and resistance training

In another RCT with 119 overweight or obese adults, aerobic exercise four to five times a week for about 30 minutes each was most effective for weight loss and fat reduction, while resistance training added lean body mass. Lean body mass is very important. It does not cause weight reduction, but rather increased fitness (J Appl Physiol. 2012 Dec;113(12):1831-1837).

With weight loss, it’s important to delineate between thin and fit. Fitness includes a body composition of decreased body fat and increased lean muscle mass. To help achieve fit level, it’s probably best to have a combination of aerobic and anaerobic exercise (resistance training). Both contribute to achieving this goal.

In conclusion, exercise can play a significant role in weight, whether with weight reduction, weight maintenance or increasing lean body mass. It appears that 30 minutes of exercise four to five times a week is best. Longer is not necessarily better.

What is most important, however, is to exercise to the point where it energizes you, but doesn’t cause fatigue. This is because it is important not to be sedentary the rest of the day, but to remain active. We should also include a complete package of lifestyle modifications in general — diet, exercise and stress reduction — to get the most compelling results.

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.

If you have been on a distant planet, you may not know that we are in the middle of the flu season. The rest of us by now have had colleagues, friends, family members, and possibly ourselves, who have confronted the influenza virus.

If you think the flu season has been worse than in recent years, you’re right. The centers for disease control preliminary data indicate outpatient visits for the flu have been more than twice the baseline (CDC.gov). The good news is that the most recent comments from the director of the CDC, Dr. Thomas Frieden, suggest that we are over the hump.

According to the CDC the present vaccine is 62 percent effective. The statistic for this year’s vaccine is derived from a case study involving 1155 children and adults (MMWR Morb Mortal Wkly Rep. 2013;62). Though this is moderate, it is still reducing the risk by more than half. However, by no means is the vaccine’s coverage perfect.

I know some have hesitancy toward the vaccine because it contains eggs and thimerosal, a preservative that is organic mercury-based. A concern is that this preservative may increase neurotoxicity risk. There are trace amounts in the flu vaccine. Those with allergies to eggs should also not receive the standard vaccine.

If you are uncomfortable with the egg or thimerosal, there is good news. The FDA has recently approved a flu vaccine, Flublox, that is both eggless and does not contain the preservative thimerosal (www. FDA.gov). It uses a recombinant DNA technology that does not require inactivated virus. It is available this year in limited quantities and will be readily available for next year’s flu season. Currently, Flublox is approved for patients 18 to 49 years old.

So what can we do to decrease the chances of getting the virus following vaccination? Actually, there are several studies that show that exercise helps boost the vaccine’s effects.

Impact of exercise

We know that exercise plays an important role in altering and improving disease processes in general, but did you know that exercise may increase the effectiveness of the flu vaccine? In particular, elderly patients tend to have weaker immune responses to pathogens, such as the flu. In a study looking at the older population, those who walked with alacrity regularly for 10 months demonstrated higher antibody levels 24 weeks after getting the flu vaccine, compared to those who stretched and did balancing exercises (J Am Geriatr Soc. 2009 Dec;57(12):2183-91). This helped boost their immunity and improved the results from the vaccine.

So what if you haven’t exercised for almost a year and are not in cardiovascular shape? Is it too late for this year’s flu season? The answer is a resounding no.

Another study showed that people who did 20 minutes of eccentric exercise using the arm that would receive the vaccine on that same day also had higher titers of antibodies several weeks later, compared to those who were sedentary (Brain Behav Immun. 2007 Feb;21(2):209-17). Women had an increase in B-cell activity, part of the immune response, six and 20 weeks later. In men, there was an increase in cell-mediated activity, another part of the immune system, which includes T-cell activity, natural killer cells and phagocytes, with levels measured eight weeks after vaccination. Participants were given the vaccine six hours after exercising.

The exercises included several sets of weighted bicep curls and lateral arm raises for the shoulders. Eccentric exercises involve lowering weights, rather than lifting them. For example, if you are doing shoulder exercises, you slowly lower the weight from your shoulder to your side. This helps to elongate the muscles.

This was a randomized controlled trial, the gold standard of studies, in 60 young, healthy adult participants. The authors surmise that the inflammation due to exercises may have been the mechanism that helped boost the effect of the vaccine.

Green tea

The great thing about green tea is that it may have benefits for many diseases and their prevention. But, did you know that green tea may actually help prevent the influenza virus? In an observational study involving over 2,000 Japanese elementary schoolchildren, those who drank green tea at least six days a week were 40 percent less likely to get the flu than those who drank green tea three or fewer days per week (J. Nutr. 2011;141(10):1862-1870). Results were confirmed using an antigen test to detect the virus.

In a separate study, health care workers who took daily green tea supplements in an RCT saw a significant reduction in the incidence of the influenza virus than the placebo group (BMC Complement Altern Med. 2011 Feb 21;11:15). The supplements contained two compounds in green tea: 378 mg of catechins and 210 mg of theanine. There were 197 participants in the study.

Hand sanitizers

Many of us use hand sanitizers regularly. Are they beneficial or dangerous? It turns out that hand sanitizers may help reduce the transmission of the flu vaccine by breaking down the lipid envelope of the virus.

In a small study, healthy participants were subjected to the flu H1N1 strain on their fingertips. They were then randomly given wipes, foam or gels that contained at least 60 percent alcohol (Am J Infect Control. 2012 Nov;40(9):806-9). It did not matter which vehicle was used to deliver the sanitizer, they all worked equally well to reduce the viral load significantly.

Be careful not to overutilize sanitizers as they may dry out the skin and cause cracking, allowing pathogens to invade the body. Sanitizers should not replace washing your hands with soap and water, but rather be an additional defense.

Although this year’s flu season seems like it is one of the more dramatic, there are ways to reduce the risk. Exercise is a great way to improve your immunity, particularly in combination with the vaccine. It may also help those who are obese, and thus may have decreased immune functioning. And drinking green tea should be easy, since flu season is during the cold weather.

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.

This week, I thought it would appropriate to talk about the significance of low iron, since I wrote about iron overload last week. The major causes of low iron are anemia of chronic disease, iron deficiency anemia, sideroblastic anemia and thalassemia. Of these, iron deficiency anemia is the most common.

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

So how do we detect iron deficiency without anemia? Not to despair, since there is a blood test done by major labs called ferritin. What is ferritin? I mentioned in my pervious article that ferritin is a protein that is involved in iron storage. When ferritin is less than 10 to 15 ng/ml, the diagnosis of iron deficiency is most likely indicated. Even healthy people with ferritin slightly higher than this level may also have iron deficiency (Br J Haematol. 1993;85(4):787-798). The normal range of ferritin is 40-200 ng/ml.

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

Effect on women

In a prospective (forward-looking) study done in 1993 looking at primary care practices, it was determined that 75 percent of patients complaining of fatigue were women (BMJ 1993;307:103). Interestingly, less than 10 percent of these women had abnormal lab results when routine labs were drawn, most probably without a ferritin level. Many of them had experienced these symptoms for at least three months.

There was a recent randomized controlled trial (RCT), the gold standard of studies, that showed women who were suffering from fatigue and low or low normal ferritin levels (less than 50 ng/ml), but who did not have anemia, benefited from iron supplementation (CMAJ. 2012;184(11):1247-1254). When comparing women with these ferritin levels, many of those that were given 80 mg of oral prolonged release ferrous (iron) sulfate supplements daily saw a significant improvement in their fatigue symptoms when compared to those women who were not given iron.

Almost half the women taking iron supplements had a significant improvement in fatigue symptoms. The results were seen in a very short 12-week period. This is nothing to sneeze at, since fatigue is one of main reasons people go the doctor. Also, although this was a small study, there were 198 women involved, ranging from 18 to 53 years old.

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

Athletes

According to a recent article, athletes’ endurance may be affected by iron deficiency without anemia (Am J Lifestyle Med. 2012;6(4):319-327). Low ferritin levels are implicated, as in the previous study. Iron is important for exercise motivation and may play a role in peak mental functioning, as reported in “Iron: Nutritional and Physiological Significance.” In animal studies, iron deficiency without anemia is associated with reduction in endurance, because of a decrease in oxygen-based enzymatic activity within the cells. However, this has not been shown definitively in human athletes and remains an interesting, but yet to be proven hypothesis.

Interestingly, female endurance athletes are more likely to be affected by iron deficiency without anemia, which occurs in about 25 percent of this population, according to studies (J Am Diet Assoc. 2005;105:975–978). Low ferritin is not seen as much in male athletes. This difference in gender may be due to the fact that women not only menstruate, losing iron on a regular basis, but also their intake of dietary iron seems to be lower (J Pediatr. 1989;114:657–663).

However, male athletes are not immune. At the end of the season for high school runners, 17 percent had iron deficiency without anemia (J Adolesc Health Care. 1987;8:322–326).

Do not take iron supplements without knowing your levels of hemoglobin and ferritin and without consulting a doctor. Studies are mixed on the benefits of iron supplementation without anemia for athletes.

Impact on restless leg syndrome

Iron deficiency with a ferritin level lower than 50 ng/ml affects approximately 20 percent of patients who suffer from restless leg syndrome (Am Fam Physician. 2000;62(4):736). Restless leg syndrome (RLS), classified as a neurologic movement disorder, causes patients to feel like they need to move their legs, most commonly about a half hour after going to bed. In a very small study, patients with restless leg syndrome who had ferritin levels lower than 45 ng/ml saw significant improvement in symptoms within eight days with iron supplementation (Sleep Med. 2012;13(6):732-735). Before you get too excited, the caveat is that 75 percent of restless leg patients have high ferritin levels.

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

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.

Iron is contained in most of the foods that we eat. It is needed for proper functioning of the body and plays an integral role in such processes as DNA synthesis and adenosine triphosphate (ATP) production, which provides energy for cells (Proc Natl Acad Sci USA. 1997;94:10919–10924). It is very important to maintain iron homeostasis, or balance.

When we think of iron, we associate it with reducing fatigue and garnering energy. In fact, many of us think of the ironman triathlons — endurance and strength come to mind. If it’s good for us, then the more we get the better right? It depends on the circumstances. But for many of us, this presumption is not grounded in reality.

Iron in excess amounts is dangerous. It may contribute to a host of diseases, including diabetes, diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, Parkinson’s disease and even heart disease. These diseases are perpetuated because when we have excess iron it may cause reactive oxygen species, or free radicals, which cause breakdown of DNA and tissues, ironically, the very things that iron homeostasis tends to preserve (Clin Haematol. 1985;14(1):129).

So what helps us differentiate between getting enough iron and iron overload? It is a good question and depends on the type of iron we ingest. There are two main types: heme iron and nonheme iron. Dietary heme, or blood, iron primarily comes from red meat and is easily absorbed into the gut. Dietary nonheme iron comes from other sources, such as plants and fortified foods, which are much more difficult sources to absorb. By focusing on the latter source of dietary iron, you may maintain homeostasis, since the gut tends to absorb 1-2 mg of iron, but also excretes 1-2 mg of iron through urine, feces and perspiration.

Not only does it matter what type of iron we consume, but also the population that ingests the iron. Age and gender are critical factors. Let me explain. Women of reproductive age, patients who are anemic and children may require more iron. However, iron overload is more likely to occur in men and postmenopausal women because they cannot easily rid the body of excess iron.

Let’s investigate some of the research that shows the effects of iron overload on different chronic diseases.

Impact on diabetes

In a recent meta-analysis (a group of 16 studies), results showed that both dietary heme iron and elevated iron storage (ferritin) may increase the risk of type 2 diabetes (PLoS One. 2012;7(7):e41641). When these ferritin levels were high, the risk of diabetes increased 66 percent to 129 percent. With heme iron, the group with the highest levels had a 39 percent increased risk of developing diabetes. There were over 45,000 patients in this analysis. You can easily measure ferritin with a simple blood test. Also these levels are modifiable through blood donation and avoidance of heme iron. Thus, reducing the risk of iron overload.

Diabetic retinopathy

Diabetic retinopathy is a complication of diabetes that occurs when glucose, or sugar, levels are not tightly controlled. It affects the retina, or the back of the eye. Iron excess and its free radicals can have detrimental effects on the retina (Methods Enzymol. 1990;186:1-85). This is potentially caused by oxidative stress resulting in retinal tissue damage (Rev Endocr Metab Disord. 2008;9(4):315-327).

So how is iron related to uncontrolled glucose levels? In vitro studies (preliminary lab studies) suggest that high glucose levels may perpetuate the breakdown of heme particles and subsequently raise the level of iron in the eye (Biophysical Chemistry. 2003;105:743-755). In fact, those with diabetic retinopathy tend to have iron levels that are 150 percent greater than those without the disease (Indian J Ophthalmol. 2004;52:145-148). Diets that are plant-based and, therefore, nutrient-dense are some of the most effective ways to control glucose levels and avoid diabetic retinopathy.

Age-related macular degeneration (AMD)

Continuing with the theme of retinal damage, excessive dietary iron intake may increase risk of AMD according to the Melbourne Collaborative Cohort Study (Am J Epidemiol. 2009;169(7):867-876). AMD is the number one cause of blindness for people 65 and older. People who consumed the most iron from red meat increased their risk of early AMD by 47 percent, however, due to the low incidence of advanced AMD among study participants, the results for this stage were indeterminate.

I have been frequently asked if unprocessed red meat is better than processed meat. Well, this study showed that both types of red meat were associated with an increased risk. This was a large study with over 5,000 participants ranging in age from 58 to 69.

Cardiovascular disease

Though we have made considerable headway in reducing the risk of cardiovascular disease and even deaths from these diseases, there are a number of modifiable risks that need to be addressed. One of these is iron overload. In the Japan Collaborative Cohort, results showed that men who had the highest amount of dietary iron were at a 43 percent increased risk of stroke death, compared to those who ate the least amounts. And overall increased risk of cardiovascular disease death, which includes both heart disease and stroke, was increased by 27 percent in men who consumed the most dietary iron. There were over 23,000 Japanese men who were between the ages of 40 to 79 that were involved in this study.

In conclusion, we should focus on avoiding heme iron, especially for men and postmenopausal women. Too much iron creates a plethora of free radicals that damage the body. Therefore, the best way to circumvent the increased risk of chronic diseases with iron overload is prevention. Significantly decreasing red meat consumption and donating blood on a quarterly basis, assuming that one is not anemic, may be the most effective strategies for not falling into the trap of iron overload.

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.

Milind Diwan

Continued from page B15

“If you measure their properties in this far-away detector, there will be differences,” Diwan predicts. “I suspect those differences will be quite large and … can be directly linked to the way the universe evolved in its first few microseconds” when antimatter was annihilated.

“We have been struggling to understand this miraculous event,” Diwan explained. “This is one of the key problems in all of science.”

While scientists plan to send the neutrinos on a long journey through the Earth, the researchers themselves are expecting their own long trek.

Based on the current plan, the LBNE will start producing data in 2022. By then, would-be scientists who are planning to graduate from high school this year may contribute to the research.

While that might seem like a slow build for a long range project, there are competitive time pressures.

“Japanese physicists want to perform a similar experiment with a shorter distance and Europeans want to perform a bigger experiment with almost the same experimental features,” Diwan explained. “At this point, there is agreement that in terms of planning, we are ahead of them.”

A resident of Port Jefferson Station, Diwan and his wife Sucheta, an engineer at Hauppauge-based Parker Hannifin, have a 14-year old daughter, Renuka, and a 10-year old son, Yashodhan.

His wife’s job is “much more important than mine,” he offers. Her company makes fuel gauges for jumbo jets.

As for his work, Diwan has been in the physics department at BNL since 1994. He is eager to see the LBNE project through.

“I feel very fortunate that I am working on a question that is important,” he offered. “It is extraordinary that we have the tools to actually perform this experiment.”

Most of us have experienced a difficult night’s sleep. However, those with obstructive sleep apnea may experience a lack of restful sleep much more frequently. OSA is an abnormal pause in breathing, while sleeping, that occurs at least five times an hour There are a surprising number of people in the United States who have this disorder. The prevalence may be as high as 20 percent of the population, and 26 percent are at high risk for the disorder (WMJ. 2009;108(5):246).There are three levels of OSA: mild, moderate and severe.

The risk factors for OSA are numerous and include chronic nasal congestion, large neck circumference, being overweight or obese, alcohol use, smoking and a family history. Not surprisingly, about two-thirds of OSA patients are overweight or obese. Smoking increases risk threefold, while nasal congestion increases risk twofold (JAMA. 2004;291(16):2013). Fortunately, as you can see from this list, many of the risk factors are modifiable.

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

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

Cardiovascular disease

In a recent observational study, the risk of cardiovascular mortality increased in a linear fashion to the severity of OSA (Ann Intern Med. 2012 Jan 17;156(2):115-22). In other words, in those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death, and in the severe group, this risk jumped considerably to 250 percent. However, the good news is that treating patients with CPAP considerably decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients. This study involved 1,116 women over a duration of six years.

Not to leave out men, another observational study showed similar risks of cardiovascular disease with sleep apnea and benefits of CPAP treatment (Lancet. 2005 Mar 19-25;365(9464):1046-53).There were more than 1,500 men in this study with a follow up of 10 years. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in stemming these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA, 38 percent and 125 percent respectively (Am J Respir Crit Care Med. 2012;186(9):909-16). But, just like in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

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

Cancer association

In sleep apnea patients under 65 years old, a recent study showed an increased risk of cancer (Am J Respir Crit Care Med. 2012 Nov. 15). The authors believe that intermittent low levels of oxygen, which are caused by the many frequent short bouts of breathing cessation during sleep, may be responsible for the development of tumors and their subsequent growth. The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. So, for those patients with more than 12 percent low-oxygen levels at night, there is a twofold increased risk of cancer development, compared to those with less than 1.2 percent low-oxygen levels.

Sexual function

It appears that erectile dysfunction may also be associated with OSA. CPAP may decrease the incidence of ED in these men. This was demonstrated in a small study involving 92 men with ED (APSS annual meeting: abstract No. 0574). The surprising aspect of this study was that, at baseline, the participants were overweight — not obese — on average and were young, at 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 percent and 27 percent respectively.

Dietary effect

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

In a small study, a low-energy diet showed positive results in potentially treating OSA. It makes sense, since weight loss is important. But even more impressively, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (BMJ. 2011;342:d3017).The results endured for at least one year. Patients studied were those who suffered from moderate-to-severe levels of sleep apnea. Low-energy diet implies a low-calorie approach. A diet that is a plant based and nutrient rich would fall into this category. Recently, one of my patients who suffered from innumerable problems was able to discontinue his CPAP machine after following this type of diet.

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

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.