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If you’re over 50, bone health should be on your radar

By David Dunaief, M.D.

Dr. David Dunaief

As the U.S. population ages, the prevalence of osteoporosis is increasing. Fifty percent of women and 25 percent of men will break a bone due to osteoporosis in their lifetimes, according to the Bone Health & Osteoporosis Foundation (1). 

Hip fractures are most concerning, because they increase mortality risk dramatically. In addition, more than 50 percent of hip fracture survivors are no longer able to live independently (2).

Does dairy consumption reduce osteoporosis risk?

The importance of drinking milk for strong bones has been drilled into us since we were toddlers. Milk has calcium and is fortified with vitamin D, so milk could only be helpful, right? Not necessarily.

The data are mixed, but studies suggest that milk may not be as beneficial as we have been raised to believe.

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (3). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. 

There was also an indication of increased mortality based on dosage: for every one glass of milk consumed, there was a 15 percent increased risk of death for women. There was a much smaller, but significant, three percent per glass increased risk of death in men. For both men and women, biomarkers were found in the urine that indicate higher levels of oxidative stress and inflammation.

This 20-year study was eye-opening. We cannot make any decisive conclusions, only associations. It does get you thinking, though. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect.

Ironically, the USDA recommends that, from the age of 9 years through adulthood, we consume about three cups of dairy per day (4). Previous studies also showed milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (5).

In a 2020 meta-analysis of an array of past studies, researchers concluded that increased consumption of milk and other dairy products did not lower osteoporosis and hip fracture risks (6).

Do calcium supplements reduce risk?

We know calcium is a required element for strong bones, but do supplements really prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food daily (7).

The researchers did not differentiate among the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers saw an increase in hip fractures among those who took calcium supplements. A weakness of this large study is that vitamin D baseline levels, exercise and phosphate levels were not considered in the analysis.

Do vitamin D supplements reduce risk?

Finally, though the data are not always consistent for vitamin D, it appears it may be valuable when it comes to fracture prevention. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (8). 

When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, those who were ages 65 and over experienced a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Where does that leave us?

Our knowledge of dietary approaches is continually evolving. Milk and dairy may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. However, the patients in these trials were not necessarily deficient in calcium nor vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, older patients may need at least 800 IUs per day.

Remember that treatment and prevention approaches should be individualized, and deficiencies in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References:

(1) www.bonehealthandosteoporosis.org. (2) EndocrinePractice. 2020 May;26(supp 1):1-46. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Crit Rev Food Sci Nutr. 2020;60(10):1722-1737. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Not all fruit raises your sugars. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Our understanding of type 2 diabetes management is continually evolving. With this, we need to retire some older guidance. Here, we review a few common myths and the research that debunks them.

Myth: Fruit should be limited or avoided.

Fact: Diabetes patients are often advised to limit fruit in any form — whether whole, juiced, or dried — because it can raise your sugars. This is only partly true.

Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. This includes dates, raisins, and apple juice, which are often added to “no sugar” foods to sweeten them. The same does not hold true for whole fruit, whether fresh or frozen. Studies have shown that patients with diabetes don’t experience sugar level spikes, whether they limit whole fruits or consume an abundance (1). In a different study, whole fruit was even shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers considered the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load, actually lowered these levels. The only fruit tested that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One reason for the beneficial effect is the fruits’ flavonoids, or plant micronutrients, but another is their fiber.

Myth: All carbohydrates raise your sugars.

Fact: Fiber is one type of carbohydrate that has distinct benefits. It is important for reducing risk for an array of diseases and for improving their outcomes. This is also true for type 2 diabetes. 

Two very large prospective observational studies, the Nurses’ Health Study (NHS) and NHS II, showed that plant fiber helped reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a direct relationship between the amount of metabolites and the reduction in diabetes risk: the more they consumed and the more metabolites in their urine, the lower the risk. The authors encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include cruciferous vegetables, such as broccoli and cauliflower; an assortment of fruits and whole grains; flaxseed; and sesame seeds (5). The researchers could not determine which plants contributed the greatest benefit; however, they believe antioxidant activity drives this effect.

Myth: You should you avoid soy when you have diabetes.

Fact: In diabetes patients with nephropathy (kidney damage or disease), soy consumption was associated with kidney function improvements (6). There were significant reductions in urinary creatinine levels and proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

This was a four-year, small, randomized control trial with 41 participants. The control group’s diet comprised 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important, since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism and low iodine levels should be cautious about soy consumption; some studies suggest it might interfere with synthetic thyroid medications’ effectiveness (8).

Myth: Bariatric surgery is a good alternative to lifestyle changes.

Fact: Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of 16 randomized control trials and observational studies, the procedure led to better results than conventional medicines over a 17-month follow-up period for HbA1C (three-month blood glucose), fasting blood glucose and weight loss (9). During this period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in diabetes remission, and many regained weight. Thus, even with bariatric surgery, altering diet and exercise are critical to maintaining long-term benefits.

We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. Emphasizing a plant-based diet focused on whole fruits, vegetables, beans and legumes can improve your outcomes. If you choose a medical approach, bariatric surgery is a viable option, but you still need to make significant lifestyle changes to sustain its benefits.

References:

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Thyroid. 2006 Mar;16(3):249-58. (9) Obes Surg. 2014;24:437-455.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Dr. Suzanne Fields, Professor of Clinical Medicine and Chief of the Division of General, Geriatric and Hospital Medicine. Photo courtesy of Stony Brook Medicine

By Daniel Dunaief

A year after its formation, the Center for Healthy Aging has not only brought groups of scientists and doctors across the Stony Brook University campus together, but has also funded several early-stage projects.

An initiative started by SBU President Maurie McInnis and that received financial support from the Stony Brook University Presidential Innovation and Excellence Fund, the CHA is currently jointly run by interim co-directors Dr. Suzanne Fields, Professor of Clinical Medicine and Chief of the Division of General, Geriatric and Hospital Medicine and Dr. Christine DeLorenzo, Professor of Psychiatry and Biomedical Engineering and Director of the Center for Understanding Biology using Imaging Technology.

The CHA has several themes, including helping people live longer and healthier lives. In addition, it will serve as a research center that will include basic science, translational, clinical and health services research.

McInnis spoke with Dr. Peter Igarashi, the Dean of the Renaissance School of Medicine at Stony Brook University, to create this initiative.

Dr. Igarashi wanted to make it a center where people from different departments in the university, the five Health Sciences Schools and the Program in Public Health, as well as affiliated institutions such as the Northport VA and the Long Island State Veterans Home collaborated on innovative projects related to aging.

Fields and DeLorenzo anticipate the collaborative research with bioinformatics, pharmacology and bioengineering, for example, will help clinical providers prescribe effective medications for older patients safely through special alerts/ suggestions, identify patients at risk for falling through mobility sensors, and assist clinical providers with AI diagnostic tools.

‘Shark Tank’

Last June, the CHA held a workshop in the style of the “Shark Tank” television show.

Over 100 faculty members attended that meeting from different parts of the university, where they formed groups with other attendees to pose research questions and address challenges people face as they age.

“There was so much enthusiasm there,” said DeLorenzo. “We have so much expertise on campus. We have brilliant researchers who are working on everything from age-related effects at the cellular level all the way through to lifestyle interventions for elderly folks.”

After that meeting, the CHA provided $40,000 to two projects, hoping the support could help ideas get off the ground enough that the principal investigators could then apply to larger funding agencies, such as the National Institutes of Health and the National Institute on Aging, for additional funding.

Led by Adam Singer, the chair of the Emergency Room department, one group of faculty developed ideas to help people who suffered from falls.

“When people who are elderly come into the ER and they’ve fallen, the chances” of them falling again doubles, according to the Centers for Disease Control and Prevention,” said DeLorenzo. “What I love about that pitch the table gave, which was a mixture of clinicians, biomedical engineers, a respiratory therapist, and a physical therapist is that people were coming at this question from all angles.”

The group pitched an idea to create an intervention program that helps explain how to change a person’s lifestyle to prevent another fall.

Senescent cells

Markus Riessland, an Assistant Professor in the Empire Innovation Program in the Department of Neurobiology and Behavior, led the other funded pitch.

Riessland’s project looks at a particular type of cell that can become problematic as people age.

Older cells sometimes get stuck in a senescent state, where they don’t die, but give off signals that cause an inflammatory response.

Riessland’s group “got together and asked, ‘How can we intervene to clear away these senescent cells?’” said DeLorenzo.

Young immune systems typically recognize senescent cells and remove them. As people age, the immune system has a diminished ability to detect and remove these cells, causing inflammaging, which describes a build up of inflammation during the aging process, Riessland explained in an email.

“If you remove senescent cells from an old mouse, these mice show improvements in the function of virtually all tissue” including heart, liver, lung and brain and the lifespan increases by 30 percent, Riessland added.

Researchers have hypothesized that there is also a threshold number of senescent cells a human body can tolerate. If a person exceeds that threshold, it “causes inflammaging and age-related symptoms,” he wrote.

Based on his laboratory work, Riessland found that specific neurons in the brain become senescent and that these neurons secrete proinflammatory factors.

Riessland and his colleagues aim to ameliorate this inflammation and have found a molecular regulator that could be a drug target.

Based on the work Riessland did through the CHA study, he and his colleagues are writing a grant proposal for the National Institutes of Health. In the future, he, DeLorenzo and Dr. Carine Maurer will perform a clinical trial on Long Island that will assess the feasibility to ameliorate the inflammaging process in patients with Parkinson’s disease.

Fall awards

In the fall, the center gave out six awards for $40,000 each and six for $100,000, many of which were in basic science, according to Dr. Fields.

“There was a broad array of topics, with some translational and some basic,” said Fields. “We’re following up with those people.”

Nancy Reich, a Professor of Microbiology & Immunology, received support as a part of the fall round.

The funding from CHA has “allowed us to begin to investigate the development of pancreatic cancer in the older population versus the young using a mouse cancer model,” Reich explained in an email. “Our hypothesis centers on the immune defense response.”

Search for a new director

Now that the center has made some headway and brought various teams together, the university is searching for a permanent director.

“It’s a real joy and pleasure to see this center start up,” said DeLorenzo.

DeLorenzo urges anyone interested in learning more to check the center’s web site, Center for Healthy Aging | Renaissance School of Medicine at Stony Brook University.

“We have events, and we would love for the community to go to them,” said DeLorenzo.

DeLorenzo encourages community members to reach out to Fields and her with any questions.

Riessland added that the CHA-funded projects will “have an impact on the understanding of the aging process itself.”

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Walking routinely can reduce your risk of dialysis.Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

In my recent article about chronic kidney disease (CKD), I wrote that about 90 percent  of the estimated 35.5 million U.S. adults who have CKD are not even aware they have it (1).

How is this possible?

CKD is typically asymptomatic in its early stages. Once it reaches moderate stages, vague symptoms like fatigue, malaise and loss of appetite can surface. It’s when it reaches advanced stages that symptoms become more evident. Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease.

What is the effect of CKD?

Your kidneys are essentially little blood filters. They remove waste, toxins, and excess fluid from your body. They also play roles in controlling your blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in your blood. When your kidneys aren’t operating at full capacity, it can cause heart disease, stroke, anemia, infection, and depression — among others.

How often should you be screened for CKD?

If you have diabetes, you should have your kidney function checked every year (2). If you have other risk factors, like high blood pressure, heart disease, or a family history of kidney failure, talk to your physician about a regular screening schedule. A 2023 Stanford School of Medicine study recommends screening all U.S. residents over age 35. The authors conclude that the cost of screening and early treatment would be lower than the long-term cost of treatment for those undiagnosed until they are in advanced stages (3). In addition, they project it will improve life expectancy.

Does basic exercise help?

One study shows that walking reduces the risk of death by 33 percent and the need for dialysis by 21 percent (4). Those who walked more often saw greater results: participants who walked one-to-two times a week had a 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a more impressive 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. The study included 6,363 participants with an average age of 70 who were followed for an average of 1.3 years.

How does protein consumption affect CKD?

With CKD, more protein is not necessarily better. It may even be harmful. In a meta-analysis of 17 studies of non-diabetic CKD patients who were not on dialysis, results showed that the risk of progression to end-stage kidney disease, including the need for dialysis or a kidney transplant, was reduced 36 percent in those who consumed a very low-protein diet, rather than a low-protein or a normal protein diet (5).

How much should I reduce my sodium consumption?

In a study, results showed that a modest sodium reduction in our diet may be sufficient to help prevent proteinuria (protein in the urine) (6). Here, less than 2000 mg per day was shown to be beneficial, something all of us can achieve.

Are some high blood pressure medications better than others?

We routinely give certain medications, ACE inhibitors or ARBs, to patients who have diabetes to protect their kidneys. What about patients who do not have diabetes? ACEs and ARBs are two classes of high blood pressure medications that work on the kidney systems responsible for blood pressure and water balance (7). Results of a study show that these medications reduced the risk of death significantly in patients with moderate CKD. Most of the patients were considered hypertensive.

However, there was a high discontinuation rate among those taking the medications. If you include the discontinuations and regard them as failures, then all who participated showed a 19 percent reduction in risk of death, which was significant. However, if you exclude discontinuations, the results are much more robust with a 63 percent reduction. To get a more realistic picture, this result, including both participants and dropouts, is probably close to what will occur in clinical practice unless patients are highly motivated.

Should you take NSAIDs?

Non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen, have been associated with CKD progression and with kidney injury in those without CKD (1). NSAIDs can also interfere with the effectiveness of ACE inhibitors or ARBs. Talk to your doctor about your prescription NSAIDs and any other over-the-counter medications and supplements you are taking.

What should I remember?

It’s critical to protect your kidneys. Fortunately, basic lifestyle modifications can help; lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options. Talk to your physician about your medications and supplements and about whether you need regular screening. High-risk patients with hypertension or diabetes should definitely be screened; however, those with vague symptoms of lethargy, aches and pains might benefit, as well.

References:

(1) cdc.gov. (2) niddk.nih.gov (3) Annals of Int Med. 2023;176(6):online. (4) Clin J Am Soc Nephrol. 2014;9(7):1183-9. (5) Cochrane Database Syst Rev. 2020;(10):CD001892. (6) Curr Opin Nephrol Hypertens. 2014;23(6):533-540. (7) J Am Coll Cardiol. 2014;63(7):650-658.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Simple tests can confirm your kidney's health. METRO photo
Simple tests can confirm your kidney’s health.

By David Dunaief, M.D.

Dr. David Dunaief

Your kidneys perform an array of critical functions that help maintain your body’s systems. They filter waste and fluid from your body and maintain your blood’s health. They also help control your blood pressure, make red blood cells and vitamin D, and control your body’s acid levels.

If your kidney function degrades, it can lead to hypertension or cardiovascular problems and it may require dialysis or a kidney transplant in later stages. For the best outcomes, it’s critical to identify chronic kidney disease (CKD) early and strive to arrest its advance to more serious stages. However, of the estimated 35.5 million U.S. adults who have CKD, as many as 9 in 10 are not even aware they have it (1).

One of the challenges with identifying early-stage CKD is that symptoms are not obvious and can be overlooked. Among them are foamy urine, urinating more or less frequently than usual, itchy or dry skin, fatigue, nausea, appetite loss, and unintended weight loss (2).

Fortunately, there are simple tests, such as a basic metabolic panel and a urinalysis, that will confirm your kidney function. These indices for kidney function include an estimated glomerular filtration rate (eGFR), creatinine level and protein in the urine. eGFR is a calculation and, while the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 is considered to have mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the severity of CKD increases.

What can be done to address early-stage CKD, before complications occur? There are several studies that have evaluated different lifestyle modifications and their impacts on its prevention, treatment and reversal.

What causes the greatest risk to your kidneys?

Among the greatest risks for your kidneys are uncontrolled diseases and medical disorders, such as diabetes and hypertension (1). If you have — or are at risk for — diabetes, be sure to control your blood sugar levels to limit kidney damage. Similarly, if you currently have hypertension, controlling it will put less stress on your kidneys. For these diseases, it’s crucial that you have your kidney function tested at least once a year.

In addition, obesity and smoking have been identified as risk factors and can be managed by making lifestyle changes to reduce your risk.

Can changing your diet help protect your kidneys?

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (3).

What is the significance of metabolic acidosis? It means that body fluids become acidic, and it is associated with CKD. The authors concluded that both sodium bicarbonate and a diet including fruits and vegetables were renoprotective, helping to protect the kidneys from further damage in patients with CKD. Alkali diets are primarily plant-based, although not necessarily vegetarian or vegan. Animal products tend to cause an acidic environment.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (4). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower eGFR levels.

The most interesting part with sodium was that the difference between higher mean consumption and the lower mean consumption was not that large, 2.4 grams compared to 1.7 grams. In other words, a difference of approximately a quarter-teaspoon of sodium per day was responsible for the decrease in kidney function.

The National Kidney Foundation recommends diets that are higher in fruit and vegetable content and lower in animal protein, including the Dietary Approaches to Stop Hypertension (DASH) diet and plant-based diets (2). 

In my practice, when CKD patients follow a vegetable-rich, nutrient-dense diet, there are substantial improvements in kidney functioning. For instance, for one patient, his baseline eGFR was 54. After one month of dietary changes, his eGFR improved by 9 points to 63, which is a return to “normal” functioning of the kidney. Note that this is anecdotal, not a study.

When should you have your kidney function tested?

It is important to have your kidney function checked. If your levels are low, you should address the issue through medications and lifestyle modifications to manage and reverse early-stage CKD. If you have common risk factors, such as diabetes, smoking, obesity or high blood pressure, or if you are over 60 years old, talk to your doctor about regular testing. 

Don’t wait until symptoms and complications occur. In my experience, it is much easier to treat and reverse CKD in its earlier stages.

References:

(1) CDC.gov. (2) kidney.org. (3) Clin J Am Soc Nephrol. 2013;8:371-381. (4) Clin J Am Soc Nephrol. 2010; 5:836-843.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Sodium’s effects are insidious

By David Dunaief, M.D.

Dr. David Dunaief

Most of us consume far too much sodium. Americans consume an average of 3400 mg per day, well over the recommended 2300 mg per day recommended upper limit for those who are 14 and over (1). These consumption numbers are even higher for some demographics. It’s become such a health problem that the FDA is getting involved, working with food manufacturers and restaurants to drive these numbers down (2). 

Why all the concern? Because even if we don’t have hypertension, sodium can have a dramatic impact on our health.

Sodium is everywhere, including in foods that don’t taste salty. Bread products are among the worst offenders. Other foods with substantial amounts of sodium include cold cuts and cured meats, cheeses, pizza, poultry, soups, pastas, sauces and, of course, snack foods. Packaged foods and those prepared by restaurants are where most of our consumption occurs.

On the flip side, only about two percent of people get enough potassium from their diets (3). According to the National Institutes of Health, adequate intake of potassium is between 2600 mg and 3400 mg for adult women and men, respectively.

What is the relationship between sodium and potassium?

A high sodium-to-potassium ratio increases our risk of cardiovascular disease by 46 percent, according to a 15-year study of more than 12,000 (4). To improve our overall health, we need to shift the sodium-to-potassium balance so that we consume more potassium and less sodium. And if you struggle with – or are at risk for – high blood pressure, this approach could help you win the battle.

Why lower your sodium consumption?

Two studies illustrate the benefits of reducing sodium in high blood pressure and normotensive (normal blood pressure) patients, ultimately preventing cardiovascular disease, including heart disease and stroke.

The first was a meta-analysis that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. It demonstrated that salt reduction from 9-to-12 grams per day to 5-to-6 grams per day had a dramatic effect. Blood pressure was reduced by a significant mean of −4.18 mm Hg systolic (top number) and −2.06 mm Hg diastolic (bottom number) involving both normotensive and hypertensive participants (5). 

When looking solely at hypertensive patients, the reduction was even greater, with a systolic blood pressure reduction of −5.39 mm Hg and a diastolic reduction of −2.82 mm Hg. The researchers believe that the more we reduce the salt intake, the greater the effect of reducing blood pressure. The authors recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

In the second study, a meta-analysis of 42 clinical trials including both adults and children, there was a similarly significant reduction in both systolic and diastolic blood pressures (6). Both demographics saw a blood pressure reduction, although the effect was greater in adults. Interestingly, an increase in sodium caused a 24 percent increased risk of stroke incidence but, more importantly, a 63 percent increased risk of stroke mortality. The risk of mortality from heart disease was increased alongside an increase in sodium, as well, by 32 percent.

Can you consume too little sodium?

Some experts warn that too-low sodium levels can be a problem. While this is true, it’s very rare, unless you take medication or have a health condition that depletes sodium. We hide sodium everywhere, so even if you don’t use a salt shaker, you’re probably consuming more than the recommended amount of sodium.

Why is potassium consumption important?

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (7). When foods containing 3.5 to 4.7 grams of potassium were consumed, there was an impressive −7.16 mm Hg reduction in systolic blood pressure with high blood pressure patients. Anything more than this amount of potassium did not provide additional benefit. Increased potassium intake also reduced the risk of stroke by 24 percent.

Blood pressure reduction was greater with increased potassium consumption than with sodium restriction, although this was not a head-to-head comparison. The good news is that it’s easy to increase your potassium intake; it’s found in many whole foods and is richest in fruits, vegetables, beans and legumes.

The bottom line: decrease your sodium intake and increase potassium intake from foods. First, consume less sodium, and give yourself a brief period to adapt — it takes about six weeks to retrain your taste buds. You can also improve your odds by increasing your dietary potassium intake, striking a better sodium-to-potassium balance.

References:

(1) Dietary Reference Intakes for Sodium and Potassium. Washington (DC): National Academies Press (US); 2019 Mar. (2) fda.gov. (3) nih.gov. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) BMJ. 2013 Apr 3;346:f1325. (6) BMJ. 2013 Apr 3;346:f1326. (7) BMJ. 2013; 346:f1378.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Exercise and diet are keys to improving discomfort for osteoarthritis pain. METRO photo
Exercise and diet are keys to improving discomfort

By David Dunaief, M.D.

Dr. David Dunaief

Osteoarthritis (OA) can make it difficult to perform daily activities and affect your quality of life. It affects the knees, hips and hands most often, and it can disturb your mobility, mood, and sleep quality.

First-line medications can help treat arthritis pain. Acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen are common. Unfortunately, they do have side effects, especially with long-term use. Also, while they might relieve your immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression.

However, you can ease your pain without reaching for medications. Some approaches might even help slow you OA’s progression or reverse your symptoms.

Does losing weight really help with OA pain?

Weight management is a crucial component of any OA pain management strategy. In a study of 112 obese patients, those who lost weight reported that their knee symptoms improved (1). Even more exciting, the study authors observed disease modification, with a reduction in the loss of cartilage volume around the medial tibia. Those who gained weight saw the opposite effect.

The relationship was almost one-to-one; for every one percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the opposite occurred when participants gained weight.

A reduction of tibial cartilage is often associated with the need for a knee replacement.

Does increasing vitamin D help reduce OA pain?

In a randomized controlled trial (RCT), vitamin D provided no OA symptom relief, nor any disease-modifying effects (2). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

In another study of 769 participants, ages 50-80, researchers found that low vitamin D levels – below 25 nmol/l led to increased OA knee pain over the five-year study period and hip pain over 2.4 years (3). The researchers postulate that supplementing vitamin D might reduce pain in those who are deficient, but that it will likely have no effect on others.

Does consuming dairy help with OA?

With dairy, specifically milk, there is conflicting information. Some studies show benefits, while others show that it might actually contribute to the inflammation that makes osteoarthritis pain feel worse.

In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (4). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

The result curve was interesting, however. For those who drank fewer than three glasses a week up to 10 glasses a week, the progression of joint space narrowing was slowed. However, for those who drank more than 10 glasses per week, there was less benefit. There was no benefit seen in men or with the consumption of higher fat products, such as cheese or yogurt.

However, the study was observational and had significant flaws. First, the 2100 patients were only asked about their milk intake at the study’s start. Second, patients were asked to recall their weekly milk consumption for the previous 12 months before the study began – a challenging task.

On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (5).

What about yogurt? A published Framingham Offspring Study analysis found that those who consumed yogurt had statistically significant lower levels of interleukin-6 (IL-6), a marker for inflammation, than those who didn’t eat yogurt, but that this was not true with milk or cheese consumption (6).

Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I might not dissuade osteoarthritis patients from yogurt.

Which is better, diet or exercise, for reducing OA pain?

Diet and exercise together actually trumped the effects of diet or exercise alone in a well-designed, 18-month study (7). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant functional improvements and a 50 percent pain reduction, as well as inflammation reduction. This was compared to those who lost a lower percent of their body weight.

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

To reduce pain and possibly improve your OA, focus on lifestyle modifications. The best effects shown are with weight loss – which is most easily achieved with a vegetable-rich diet and exercise. In terms of low-fat or nonfat milk, the results are controversial, at best. For yogurt, the results suggest it may be beneficial for osteoarthritis, but stay on the low end of consumption, since dairy can increase inflammation.

References:

(1) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (2) JAMA. 2013;309:155-162. (3) Ann. Rheum. Dis. 2014;73:697–703. (4) Arthritis Care Res online. 2014 April 6. (5) J Rheumatol. 2017 Jul;44(7):1066-1070. (6) Nutrients. 2021 Feb 4;13(2):506. (7) JAMA. 2013;310:1263-1273.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Try eating a more plant-based, whole foods diet. METRO photo
Cardiac biomarkers can help you monitor your progress

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is on the decline in the U.S. Several factors have influenced this, including better awareness, improved medicines, earlier treatment of risk factors and lifestyle modifications (1). Still, we can do better. Heart disease still underpins one in four deaths, and it is preventable.

What are the baseline risks for heart disease?

Significant risk factors for heart disease include high cholesterol, high blood pressure and smoking. In addition, diabetes, excess weight and excessive alcohol intake increase your risks. Unfortunately, both obesity and diabetes rates are increasing. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2).

Inactivity and the standard American diet, which is rich in saturated fat and calories, also contribute to atherosclerosis, or fatty streaks in the arteries, the underlying culprit in heart disease risk (3).

A less-discussed risk factor is a resting heart rate greater than 80 beats per minute (bpm). A normal resting heart rate is typically between 60 and 100 bpm. If your resting heart rate is in the high-normal range, your risk increases.

In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (4). The good news is that you can reduce your risks.

Does medication lower heart disease risk?

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. Unfortunately, according to 2018 National Health and Nutrition Examination Survey (NHANES) data, only 43.7 percent of those with hypertension have it controlled (5). While the projected reasons are complex, a significant issue among those with diagnosed hypertension is their failure to consistently take their prescribed medications.

Statins have played a key role in primary prevention, as well. They lower lipid levels, including total cholesterol and LDL (“bad” cholesterol). They also lower inflammation levels that contribute to cardiovascular disease risk. The JUPITER trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

The downside of statins is their side effects. Statins have been shown to increase the risk of diabetes in intensive dosing, when compared to moderate dosing (6).

Unfortunately, another side effect of statins is myopathy (muscle pain). I have a number of patients who suffered from statin muscle pain and cramps shift their focus to diet and exercise to get off their prescriptions. Lifestyle modification is a powerful ally.

Do lifestyle changes really reduce heart disease risk?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required modest dietary changes.

The Nurses’ Health Study shows that these results are also seen in women, with lifestyle modification reducing the risk of sudden cardiac death (SCD). Many times, this is the first manifestation of heart disease in women. The authors looked at four parameters of lifestyle modification, including a Mediterranean-type diet, exercise, smoking and body mass index. The decrease in SCD was dose-dependent, meaning the more parameters adopted, the greater the risk reduction. SCD risk was reduced up to 92 percent when all four parameters were followed (8). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

How can you monitor your progress in lowering heart disease risk?

To monitor your progress, cardiac biomarkers, such as blood pressure, cholesterol, body mass index, and inflammatory markers like C-reactive protein can tell us a lot.

In a cohort study of high-risk participants and those with heart disease, patients began extensive lifestyle modifications: a plant-based, whole foods diet accompanied by exercise and stress management (9). The results showed improvements in biomarkers, as well as in cognitive function and overall quality of life. Most exciting is that results occurred over a very short period to time — three months from the start of the trial. Many of my patients have experienced similar results.

Ideally, if a patient needs medications to treat risk factors for heart disease, it should be for the short term. For some patients, it makes sense to use medication and lifestyle changes together; for others, lifestyle modifications may be sufficient, provided the patient takes an active role.

References:

(1) cdc.gov/heartdisease/facts. (2) Diabetes Care. 2010 Feb; 33(2):442-449. (3) Lancet. 2004;364(9438):93. (4) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (5) Hypertension. 2022;79:e1–e14. (6) JAMA. 2011;305(24):2556-2564. (7) J Nutr. March 1, 2005;135(3):556-561. (8) JAMA. 2011 Jul 6;306(1):62-69. (9) Am J Cardiol. 2011;108(4):498-507.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Focus less on balancing protein, carbohydrates and fats

By David Dunaeif, M.D.

Dr. David Dunaief

The road to weight loss, or even weight maintenance, is complex. There are many things that influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

Knowing a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or can actually encourage higher calorie purchases (1, 2). The good news is that controlling weight isn’t solely about exercising willpower. Instead, we need to change our diet composition.

In my clinical experience, increasing food quality has a tremendous impact. Focusing on foods that are the most micronutrient dense tends to be the most satisfying, rather than focusing on foods’ macronutrient density, such as protein, carbohydrates and fats. In a week to a few months of emphasizing micronutrients, one of the first things patients notice is a significant reduction in cravings.

Are refined carbohydrates bad for you?

Generally, we know that refined carbohydrates don’t help. Looking deeper, a small, randomized control trial (RCT) showed refined carbohydrates actually may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown with MRI scans of trial subjects.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were unaware of which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number of calories consumed. Commonly found high-glycemic foods include items like white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates.

What’s the right balance of protein, carbohydrates and fats?

We tend to focus on macronutrients — protein, carbohydrates, and fats — when we look at diets. Which has the greatest impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among study groups, nor was there much success in helping obese patients reduce their weight (4, 5). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Focusing primarily on macronutrient levels and calorie counts did very little to improve results.

What’s the relationship between           micronutrients and weight?

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be micronutrient-deficient (6). Micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements doesn’t solve the problem; generally, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation, by increasing the variety of foods in your diet. Please ask your doctor.

Long-term benefits of reducing              cortisol levels

Cortisol raises blood-levels of glucose and is involved in promoting visceral or intra-abdominal fat. This type of fat can coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality.

The good news is that once people lose weight, it may be easier to continue to keep weight off. In a prospective (forward-looking) study, results show that once obese patients lost weight, the levels of cortisol metabolite excretion decreased significantly (7). This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about calorie-counting. While calorie intake has a role, food’s nutrient density may be more important to your success and may play a significant role in reducing your cravings, ultimately helping you manage your weight.

References:

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) Am J Clin Nutr Online 2013;Jun 26. (4) N Engl J Med 2009 Feb 26;360:859. (5) N Engl J Med 2009 Feb 26;360:923. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Antibiotic use can affect the microbiome

By David Dunaief, M.D.

Dr. David Dunaief

Each of us has a microbiome — trillions of microbes that include bacteria, viruses and single-cell eukaryotes that influence our body’s functions. When “good” and “bad” microbes are in balance, we operate without problems. However, when the balance is tipped, often by environmental factors, such as diet, infectious diseases, and antibiotic use, it makes us more susceptible to diseases and disorders.

While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where most of our microbiome lives.

Research into the specifics of our microbiome’s role in healthy functioning is still in its infancy. Current research into the microbiome’s effects include its role in obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

What influences our microbiome?

Lifestyle, such as diet, can impact our microbiome positively or negatively. Microbiome diversity may be significantly different in distinct geographic locations throughout the world, because diet and other environmental factors play such a large role.

When we take drugs, such as antibiotics, we can wipe out our microbial diversity, at least in the short term. This is why many have gastrointestinal upset while taking antibiotics. Antibiotics don’t differentiate between good and bad bacteria when they go to work.

One way to counteract these negative effects is to take a probiotic during and after your course of antibiotics. I recommend Renew Life’s 30-50 billion units once a day, two hours after an antibiotic dose and continuing once a day for 14 days after you have finished your prescription. If you really want to ratchet up the protection, you can take one dose of probiotics two hours after each antibiotic dose.

How does the microbiome affect weight?

Many obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

For a long time, the paradigm for weight loss had been to cut calories. However, extreme low-calorie diets were not having a long-term impact. It turns out that our guts may play important roles in obesity and weight loss, determining whether we gain or lose weight.

The results from a study involving human twins and mice are fascinating (2). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. Interestingly, they only lost weight when on a good diet. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not yet clear which bacteria may be contributing these effects.

Does gut bacteria contribute to the development of rheumatoid arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant joint soreness and joint breakdown. What if gut bacteria influenced RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (3). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Although we can’t yet say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, can affect the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. The research is continuing, but we’ve learned a lot already.

References:

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) Science. 2013;341:1241214. (3) PLoS One. 2012;7:e36095. (4) Nutrients. 2019 Dec;11(12):2862.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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