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Even modest exercise can affect your genes. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that we should not rely on exercise for weight loss. Exercise is still important, though. It can alter how our genes express themselves and improve our outcomes with diseases and other health issues, such as diabetes, kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Despite all the positives, it can be difficult to motivate yourself to exercise. However, there are some simple ways to motivate yourself during exercise. One study showed that those who repeated positive mantras to themselves during exercise were able to persist for longer periods (2).

Why is this so important? Because we are too sedentary, and this is the time of the year when we are especially so. According to data from the 2015-2018 Behavioral Risk Factor Surveillance System, the Northeast had among the highest levels of physical inactivity in the U.S., at 25.6 percent of the population (3).

Does exercise alter your genes?

While it may not change our genes, exercise may change how our genes express themselves.

One study’s results showed that thousands upon thousands of genes in fat cells were affected when participants exercised for six months (4). During the study, sedentary men exercised twice a week at a one-hour spin class. According to the researchers, this affected genes that are involved in storing fat and in risk for subsequent diabetes and obesity development. The participants also improved other important health metrics, including their cholesterol, blood-pressure, fat percent and, later, their waist circumferences.

The effect identified on the fat cells is referred to as epigenetics, where lifestyle modifications ultimately lead to changes in gene expression, turning them on and off. This has been shown with dietary changes, but this is one of the first studies to show that exercise also has significant impacts on our genes. It took only six months to see these numerous gene changes with modest amounts of cardiovascular exercise.

Want more encouragement? Another study showed considerable gene changes in muscle cells after one workout on a stationary bike (5). Yet another introduced six weeks of endurance exercise to healthy, but sedentary, young men and identified an abundance of genetic changes to skeletal muscle, which has broad impacts on physical and cognitive health (6).

Can you treat cardiovascular disease with exercise?

What if we could forgo medications for cardiovascular disease by exercising? One meta-analysis examined 57 studies that involved drugs and exercise. It showed similar benefits in mortality with secondary prevention of coronary heart disease with statins and exercise (7). So, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same study also showed that for those with pre-diabetes, it didn’t matter whether they took metformin or exercised – they had the same effect.

While these results are exciting, don’t change your medication without consulting your physician.

Does exercise help with kidney stones?

Anyone who has tried to pass a kidney stone knows it can be excruciating. Most treatments involve taking pain medication and fluids and just waiting for the stone to pass. Truly, the best way to treat kidney stones is to prevent them.

In the Women’s Health Initiative Observational Study, exercise reduced the risk of kidney stones by as much as 31 percent (8). Even better, the intensity of exercise did not change its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results; however, lesser amounts of exercise also saw substantial reductions. This study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones.

Does sexual activity count as exercise?

We have heard that sex is a form of exercise, but is this a myth or is there actual evidence? According to research, this may be true. In a study, researchers found that young, healthy couples exert 6 METs — metabolic energy, or the amount of oxygen consumed per kilogram per minute — during sexual activity (9).

How does this compare to other activities? We exert about 1 MET while sitting and 8.5 METs while jogging. In terms of energy used, sexual activity can be qualified as moderate activity. Men and women burned almost half as many calories with sex as with jogging, burning a mean of 85 calories over about 25 minutes. Who says exercise can’t be fun?

Movement and exercise not only help you feel better, they may also influence your genes’ expression. In certain circumstances, they may be as powerful as medications in preventing some diseases.

References:

(1) JAMA. 2009;301(19):2024. (2) Med Sci Sports Exerc. 2013 Oct 10. (3) cdc.gov. (4) PLoS Genet. 2013 Jun;9(6):e1003572. (5) Cell Metab. 2012 Mar 7;15(3):405-11. (6) Mol Metab. 2021 Nov;53:101290. (7) BMJ. 2013; 347. (8) JASN. 2013;24(3):p 487-497. (9) PLoS One 8(10): e79342.

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 without dietary changes may not help you lose weight. METRO photo
Exercise without dietary changes may not help you lose weight

By David Dunaief

Dr. David Dunaief

We’re just past the point on the calendar when those who committed to exercising more in the new year are likely to have fallen off their resolutions. If you’re still following through, congratulations!

Exercise has benefits for a wide range of medical conditions, from depression, insomnia, fatigue and balance to cognitive decline, chronic kidney disease, diabetes, cardiovascular disease and osteoporosis.

Will it help you lose weight, though? While gym membership ads emphasize this in January, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. It may, however, be helpful with weight maintenance.

Ultimately, it may be more important to examine what you are eating than to succumb to the rationalization that you can eat without care and work it off later.

Will exercise help you lose weight?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will tip the scale in favor of weight loss. The more you burn, the more you will lose. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

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

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

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

Does exercise play a role in weight maintenance?

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

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects roughly one in seven U.S. adults, as a simple example of exercise’s impact on disease (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (8). There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

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

There are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

By all means, exercise, but to lose weight, also focus on consuming nutrient-dense foods instead of calorie-dense foods that you may not be able to exercise away.

References:

(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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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Blueberries have been known to lower blood pressure. METRO photo
Over 77 percent of hypertension is uncontrolled.

By David Dunaief, M.D.

Dr. David Dunaief

You would think that, with all the attention we place on hypertension and all the medications in the market that focus on reducing it, we would be doing better in the U.S., statistically.

According to the latest data, almost 120 million U.S. adults, or 48.1 percent of the population, suffer from hypertension (1). Of these, only 22.5 percent have their blood pressure controlled to less than 130/80 mmHg.

For the remaining 92.9 million affected, their risk of complications, such as cardiovascular events and mortality, is significantly higher.

What has the greatest impact on your risk of developing hypertension?

In an observational study involving 2,763 participants, results showed that the top three influencers on the risk of developing high blood pressure were eating a poor diet, with 2.19 times increased risk; being at least modestly overweight, with 1.87 times increased risk; and cigarette smoking, which increased risk 1.83 times (2).

What increases our risk of hypertension complications?

Being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, diabetes, low vitamin D, and too much alcohol are some of the factors that increase our risk (3). The good news is that you can take an active role in improving your risk profile (4).

Who is at greater risk of complications, men or women?

One of the most feared complications of hypertension is cardiovascular disease. A study found that isolated systolic (top number) hypertension increased the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (5). The effect was greatest in women, with a 55 percent increased risk of cardiovascular disease and 112 percent increased risk of heart disease death. 

High blood pressure complications were not affected by onset age. Though this study was observational, it was very large and had a 31-year duration.

When is the best time to measure blood pressure?

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis of nine studies, results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (5).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events.

Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

Masked uncontrolled hypertension (MUCH) is a factor that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most seen during nocturnal hours (6). 

The authors suggest that ABPM may be a better way to monitor those with higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

A previous study of patients with chronic kidney disease (CKD) and hypertension suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (7). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. This could help explain those results.

Do berries help control blood pressure?

Diet plays an important role in controlling high blood pressure. Of course, lowering sodium is important, but what about adding berries?

In a study, 22 grams of blueberry powder consumed daily, equivalent to one cup of fresh blueberries, reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (8).

This modest amount of fruit had a significant impact in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase nitric oxide, which helps blood vessels relax and reduces blood pressure. While the study used powder, it’s possible that an equivalent amount of real fruit could lead to an even greater reduction.

In conclusion, high blood pressure and resulting cardiovascular complications can be scary, but lifestyle modifications, such as making dietary changes and taking antihypertensive medications at night, can have a big impact in reducing your risks.

References:

(1) millionhearts.hhs.gov. (2) BMC Fam Pract 2015;16(26). (3) uptodate.com. (4) Diabetes Care 2011;34 Suppl 2:S308-312. (5) J Am Coll Cardiol 2015;65(4):327-335. (6) Eur Heart J 2015;35(46):3304-3312. (7) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (8) J Acad Nutr Diet 2015;115(3):369-377.

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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Key changes can significantly reduce heart disease risk. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

In February, we celebrate Valentine’s Day, a celebration of those we love, alongside American Heart Month, an invitation for us to build our awareness of heart-healthy habits.

The good news is that heart disease is on the decline due to several factors, including improved medicines, earlier treatment of risk factors, and an embrace of lifestyle modifications. While we are headed in the right direction, we can do better. Heart disease is ultimately preventable.

Can we reduce heart disease risks?

Major risk factors for heart disease include obesity, high cholesterol, high blood pressure, smoking and diabetes. Sadly, rates of both obesity and diabetes are rising. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (1).

Key contributors also include inactivity and the standard American diet, which is rich in saturated fat and calories (2). This drives atherosclerosis, fatty streaks in the arteries.

Another potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). 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 (3). A normal resting heart rate is usually between 60 and 100 bpm. Thus, you don’t have to have a racing heart rate, just one that is high-normal. All of these risk factors can be overcome.

When does medication help?

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. Compliance with taking blood pressure medications has increased over the last 10 years from 33 to 50 percent, according to the American Society of Hypertension.

Statins have also played a key role in primary prevention. They are effective at lowering lipid levels, including total cholesterol and LDL — the “bad” cholesterol. In addition, they lower the 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, compared to moderate dosing (4). Many who are on statins also suffer from myopathy (muscle pain and cramping).

I’m often approached by patients on statins with this complaint. Their goal when they come to see me is to reduce and ultimately discontinue statins by modifying their diet and exercise plans.

Lifestyle modification is a powerful ally.

How much do lifestyle changes reduce heart disease risk?

The Baltimore Longitudinal Study of Aging 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 (5). 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 a modest change in diet.

The Nurses’ Health Study shows that these results are also seen in women. Lifestyle modification reduced the risk of sudden cardiac death (SCD) (6). 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. There was a decrease in SCD that was dose-dependent, meaning the more factors incorporated, the greater the risk reduction. There was as much as a 92 percent decrease in SCD risk when all four parameters were followed. Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

In a cohort study of high-risk participants and those with heart disease, patients implemented extensive lifestyle modification: a plant-based, whole foods diet accompanied by exercise and stress management. The results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life. The best part is the results occurred over a very short period — three months from the start of the trial (7). Outside of this study environment, many of my own patients have experienced similar results.

How do you monitor your heart disease risk?

Physicians use cardiac biomarkers, including blood pressure, cholesterol and body mass index, alongside inflammatory markers like C-reactive protein to monitor your risk. Ideally, if you need to use medications to treat risk factors for heart disease, it should be for the short term. For some patients, it may be appropriate to use medication and lifestyle changes together; for patients who take an active role, lifestyle modifications may be sufficient.

By focusing on developing heart-healthy habits, you can improve the likelihood that you— and those you love — will be around for a long time.

References:

(1) Diabetes Care. 2010 Feb; 33(2):442-449. (2) Lancet. 2004;364(9438):93. (3) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (4) JAMA. 2011;305(24):2556-2564. (5) J Nutr. March 1, 2005;135(3):556-561. (6) JAMA. 2011 Jul 6;306(1):62-69. (7) 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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Are OTC medications really low risk? METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Many of us keep a supply of over-the-counter medications for pain relief, fever and inflammation in our medicine cabinets. Typical “staples” are acetaminophen and a variety of NSDAIDs (non-steroidal anti-inflammatory drugs), like aspirin, ibuprofen, naproxen sodium and diclofenac sodium. These tend to be our “go to” medications when something ails us.

Americans consume more than 30 billion doses of NSAIDs a year, including both over-the-counter (OTC) and prescription-strength (1). As for acetaminophen, also known by the brand name Tylenol, one quarter of Americans take it weekly.

Unfortunately, many think these drugs are low risk, because they’re so accessible and commonplace. Many of my patients don’t even include them in a list of medications they take. I have to specifically ask about them. According to a poll of regular OTC NSAID users, 60 percent were not aware that they can have dangerous side effects (2).

What are risks of taking NSAIDs?

Unfortunately, NSAIDs, according to the Centers for Disease Control and Prevention, are responsible for 7,600 deaths annually and 10 times that number in hospitalizations (3). 

NSAIDs increase the risk of heart attacks, gastrointestinal bleeding, stroke, exacerbation of diverticular disease, chronic arrhythmias (abnormal heartbeats) and erectile dysfunction. In some instances, the cardiovascular effects can be fatal.

These risks prompted the FDA to strengthen the warning labels on non-aspirin NSAID labels in 2015, advising that those taking NSAIDs should immediately seek medical attention if they experienced chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech (4).

As recently as late 2020, the FDA added a warning label to non-aspirin NSAIDs about the potential for fetal kidney damage and pregnancy complications beginning around week 20 of a pregnancy (4).

In a case control study using the UK Primary Care Database, chronic users of NSAIDs between ages 40 and 89 had a significantly increased risk of a serious arrhythmia (abnormal heartbeat) called atrial fibrillation (5).

Interestingly, researchers defined “chronic users” as patients who took NSAIDs for more than 30 days. These users had a 57 percent increased risk of atrial fibrillation. A Danish study reinforces these results after the first month of use (6). This is not very long to have such a substantial risk. For patients who used NSAIDs longer than one year, the risk increased to 80 percent. 

NSAIDs also increase the risk of mortality in chronic users. Older patients who have heart disease or hypertension (high blood pressure) and are chronic NSAIDs users are at increased risk of death, according to an observational study (7). Compared to those who never or infrequently used them over about 2.5 years, chronic users had a greater than twofold increase in death due to cardiovascular causes. 

High blood pressure was not a factor in this study, since the chronic users actually had lower blood pressure; however, I have seen that NSAID use can increase blood pressure with some of my patients.

What are the risks of acetaminophen?

The FDA announced in 2011 that acetaminophen should not exceed 325 mg every four to six hours when used as a prescription combination pain reliever (4). The goal is to reduce and avoid severe injury to the liver, which can cause liver failure.

There is an intriguing paradox with acetaminophen: Hospitals typically dispense regular-strength 325-mg doses of the drug, whereas OTC doses frequently are found in “Extra Strength” 500-mg tablets, and often the suggested dose is two tablets, or 1 gram. At the FDA’s request, Tylenol lowered its recommended daily dosage for extra strength Tylenol to no more than 3 grams a day.

One study that showed acute liver failure was due primarily to unintentional overdoses of acetaminophen (8). Accidental overdosing is more likely to occur when taking acetaminophen at the same time as a combination sinus, cough or cold remedy that also contains acetaminophen. OTC and prescription cold medications can contain acetaminophen.

Of course, if you already suffer from liver damage or disease, consult your physician before taking any medications.

In order to protect yourself from potentially adverse events, you must be your own best advocate; read labels, and remember to tell your physician if you are taking any OTC medications.

If you are a chronic user of NSAIDs or acetaminophen because of underlying inflammation, you may find an anti-inflammatory diet is an effective alternative.

References:

(1) Medscape.com, 2021 Oct 21 (emedicine.medscape.com/article/816117-overview). (2) J Rheumatol. 2005;32;2218-2224. (3) Annals of Internal Medicine, 1997;127:429-438. (4) fda.gov (5) Arch Intern Med. 2010;170(16):1450-1455. (6) BMJ 2011;343:d3450. (7) Am J Med. 2011 Jul;124(7):614-620. (8) Am J Gastroenterol. 2007;102:2459-2463.

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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You’ll be surprised at how much better you will feel — and how much sharper your thinking is if you add walking to your daily regimen. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

What does it take to get us out of our seats? We know that exercise is good for our long-term physical and mental health, but it’s still elusive for many of us. It’s just too tempting to let the next episode of our new favorite series autoplay or to answer those last few emails.

Many of us tried to get out of gym class as kids and, as adults, we “want” to exercise, but we “don’t have time.” I once heard that the couch is as bad as the worst deep-fried food; it perpetuates inactivity. Even sleeping burns more calories than sitting and watching TV.

I have good news. There is an easy way to get tremendous benefit in very little time. You don’t need expensive equipment, and you don’t have to join a gym. You can even sharpen your wits — with your feet.

The New York Times’ Science Times carried an article a few years ago about Esther Tuttle. At the time, Esther was 99 years old, sharp as a tack and was independently mobile, with no mobility aids required. She continued to stay active by walking in the morning for 30 minutes and then walking again in the afternoon. The skeptic might say that this is a nice story, but its value is anecdotal at best.

Well, evidence-based medicine backs up her claim that walking is a rudimentary and simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away. For the step-counters among you, that’s about 2,000 steps a day for an adult with an average stride length.

Does walking improve brain function?

Walking also has a powerful effect on preserving brain function and even growing certain areas of the brain (1). Walking between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years. Whoa!

Participants who had an increase in brain tissue volume also had a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants who were dementia free at the start of the trial. The mean participant age was 78. Imagine if you started younger?

In yet another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2).

Even better news is that, if you’re pressed for time or if you’re building up your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile? You’ll be surprised at how much better you will feel — and how much sharper your thinking is.

How does walking affect mood?

Researchers performed a meta-analysis of other studies related to the relationship between exercise and depression. They found that adults who walked briskly for about 75 minutes per week cut their risk of depression by 18 percent (3). That’s only half of what the Centers for Disease Control recommend. 

If you ratchet up your exercise to running, a study showed that mood also improves, mollifying anger (4). The act of running actually increases your serotonin levels, a hormone that, when low, can make people agitated or angry. So, exercise may actually help you get your aggressions out.

How do I reset my sitting ‘habit?’

A particular challenge I hear these days is that working from home reduces much of the opportunity to walk. There’s less walking down the hall to a meeting or to refill your water bottle. Instead, everything is only a few steps away. It’s as if our work environment is actually working against us.

If you need a little help getting motivated, here is a terrific strategy to get you off the couch or away from your computer: set an alarm for specific points throughout your day and use that as a prompt to get up and walk, even if it’s for only 15 minutes. The miles will add up quickly.

A client of my wife’s schedules meetings for no more than 50 minutes, so she can walk a “lap” around her house’s interior between meetings. She also looks for opportunities to have a good old-fashioned phone call, rather than a video call, so she can walk around while she’s talking or listening. Of course, this is one person, but it might give you some ideas that will work for you.

Walking has other benefits as well. We’ve all heard about the importance of doing weight-bearing exercise to prevent osteoporosis and osteoporotic fractures. Sadly, if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles.

So, remember, use your feet to keep your mind sharp and yourself even-tempered. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References:

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) JAMA Psychiatry 2022. 79(6), 500-559. (4) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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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Our genes are not destiny. METRO photo

By David Dunaief, M.D.

Heart disease risk is influenced by family history and by lifestyle, including diet. But what if we could tackle genetic issues with diet?

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

The role of genes in heart disease

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It aligns with what we see in modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, such as with a plant-rich diet, such as a Mediterranean-type diet.

Does diet affect our genetic response?

A New England Journal of Medicine study explores the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet, with participants randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, risk improvement in the Mediterranean-type diet arms occurred even though there was no significant weight loss.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The Mediterranean-type diet arms both included significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence,” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two opposing opinions, split by field. You may be surprised by which group liked it and which did not.

Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring meaningful clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more people, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

So, what have we learned? Even with a genetic propensity for cardiovascular disease, we can alter our cardiovascular destinies with diet.

References:

(1)www.uptodate.com (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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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METRO photo

By David Dunaief

Dr. David Dunaief

Happy 2024! If you’ve watched any media in the past week, you’ve probably been inundated by ads for weight loss plans, apps and other tools intended to help us achieve our New Year’s resolutions. Many of these are oriented around helping us increase the “stickiness factor” of our new habits.

Setting a goal that is simple and singular helps. We often overdo it by focusing on an array of resolutions, like eating better, exercising, developing better sleep habits, and managing stress better. While these are all admirable, their complexity diminishes your chances of success. Instead, pick one to focus on, and make the desired impact part of your goal, for example: improve health by losing weight and reversing disease. 

Changing habits is always hard. There are some things that you can do to make it easier, though. 

Your environment is very important. According to David Katz, M.D., Director, Yale-Griffin Prevention Research Center, it is not as much about willpower as it is about your environment. Willpower, Dr. Katz notes, is analogous to holding your breath underwater; it is only effective for a short time. Instead, he suggests laying the groundwork by altering your environment to make it conducive to attaining your goals. Recognizing your obstacles and making plans to avoid or overcome them reduces stress and strain on your willpower. 

According to a study, people with the most self-control utilize the least amount of willpower, because they take a proactive role in minimizing temptation (1). If your intention is to eat better, start by changing the environment in your kitchen to one that prompts healthy food choices.

Support is another critical element. It can come from within, but it is best when reinforced by family members, friends and coworkers. In my practice, I find that patients who are most successful with lifestyle changes are those whose household members are encouraging or, even better, when they participate in at least some portion of the intervention, such as eating the same meals.

How long does it take to form a new habit?

When does a change become a new habit, or automaticity? The rule of thumb used to be it takes approximately three weeks of daily practice. However, the results of a study at the University of London showed that the time to form a habit, such as exercising, ranged from 18 days to 254 days (2). The good news is that, though there was a wide variance, the average time to reach this automaticity was 66 days, or about two months.

How do you choose a diet that will help you achieve your goals?

US News and World Report ranks diets annually and sorts them by objective, such as weight loss, healthy eating, diabetes diets, heart-healthy diets, etc. (3). Three of the diets highlighted include the Mediterranean diet, the DASH (Dietary Approach to Stop Hypertension) diet, and the Flexitarian diet, ranked one through three, respectively. These were also the top three for healthy eating, for diabetes, and for heart health, although their rankings among the top three shift in some cases.

What do all the top diets have in common? They focus on nutrient-dense foods. In fact, the lifestyle modifications I recommend are based on a combination of the top diets and the evidence-based medicine that supports them.

For instance, in a randomized cross-over trial, which means patients, after a prescribed time, can switch to the more effective group, showed that the DASH diet is not just for patients with high blood pressure. The DASH diet was more efficacious than the control diet in terms of diabetes, decreasing hemoglobin A1C 1.7 percent and 0.2 percent, respectively; weight loss, with patients losing 5 kg/11 lbs. vs. 2 kg/4.4 lbs. It also achieved better results with HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (4).

Interestingly, patients still lost weight, although caloric intake and the percentages of fats, protein and carbohydrates were the same between the DASH and control diets. However, the DASH diet used different sources of macronutrients. The DASH diet also contained food with higher amounts of fiber, calcium and potassium and lower sodium than the control diet. 

Therefore, diets high in nutrient-dense foods may be an effective way to lose weight while also treating and preventing disease. 

I will share one more tip: take it day by day, rather than obsessing over the larger picture. I have found many patients make better headway by choosing to change one meal at a time — like starting with what they choose to eat for breakfast or for snacks each day. Once this is a habit, they shift their focus to another meal.

Best to you for optimal health in 2024!

References:

(1) J Pers Soc Psychol. 2012;102: 22-31. (2) European Journal of Social Psychology, 40: 998–1009. (3) www.usnews.com/best-diet. (4) Diabetes Care. 2011;34: 55-57.

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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METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

It’s that time of year again and, like so many others, I have a last-minute request. You are a model for kindness and generosity around the world, for which I’m grateful. I would like you to be a role model in another arena, as well — health.

Kids marvel at your round belly, which shakes when you laugh like a bowl full of jelly. They literally feed that belly by setting out cookies and other sweets for you on Christmas Eve to sustain you during your travels.

I have nothing against your round belly, but I’m concerned about the message it sends. We’re currently facing an epidemic of overweight kids and an ever-increasing number of children with type 2 diabetes. According to the CDC, the percentage of U.S. children between ages 10 and 19 with type 2 diabetes nearly doubled from 2001 to 2017. You, Santa, with your influence, can help reverse this trend.

Obesity has a high risk of shortening your life span, not to mention affecting your quality of life. The most dangerous type of obesity is visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if their waistline, measured from the navel, is 40 inches or more for a man and 35 inches or more for a woman. Risks for pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is your opportunity to lead by example — and, maybe fit back into that skinny tracksuit you’ve had in the back of your closet since the 16th century, when you were trim.

Think of the personal advantages of losing that extra belly weight. Your joints won’t ache with the winter cold; it will improve your posture, so your back doesn’t hurt as much; and you will have more energy. Plus, studies show that a diet that emphasizes fruits, vegetables and whole grains can reverse clogged arteries and help you avoid strokes, heart attacks and peripheral vascular disease. With a simple change, like eating a small handful of raw nuts each day, you can reduce your heart disease risk significantly.

Losing weight will also change your center of gravity, which will make it easier for you to keep your balance on those steep, snowy rooftops. No one wants you to take a tumble and risk a broken bone – or worse.

Exercise will help, as well. Maybe this Christmas Eve, you could walk or jog alongside the sleigh for the first continent or so. During the “offseason” you and the elves could form small groups of workout buddies to keep each other on track with your workout goals. And who doesn’t love an impromptu game of tag with the reindeer? With time, you’ll start to tighten your abs and slowly see fat disappear from your midsection.

This might also make it easier to steal a base or two during the North Pole Athletic League’s Softball season. The elves don’t even bother holding you on base anymore, do they?

Of course, the cookies don’t help. You might take a cue from the reindeer, who love their raw carrots and celery. Broadcast that the modern Santa enjoys fruits, especially berries and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in humus, which have substantial antioxidant qualities and can help reverse disease.

And, of course, skip putting candy in our stockings. We don’t need more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a few pieces. Why not reduce the temptation? This will also help you minimize the waves of fatigue you feel as you pull your worldwide all-nighter.

As for your loyal fans, you could place active games under the tree. You and your elves could create an app or website with free workout videos for those of us who need them; we could follow along as you showed us “12 Days of Dance-Offs with Santa and Friends.”

You could gift athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games. Or wearable devices that track step counts and bike routes. Or stuff gift certificates for dance lessons into people’s stockings.

As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll be able to park the sleigh farther away and skip from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Your reindeer won’t have to work as hard. You might fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!

Wishing you good health in the coming year,

David

P.S. If you have a little extra room in your sleigh, I could use a new baseball bat. I know the Yankees need help, so I’ve been practicing.

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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Most thyroid nodules are found incidentally. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Thyroid nodules are often diagnosed incidentally on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck. It’s rarely because of symptoms. More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound. Fortunately, most are benign. Depending on the study, the percent that are malignant can range from 1.1 to 6.5 percent of nodules. 

This leaves us with the question of what to do with a thyroid nodule. What’s the short answer? It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA). While most are asymptomatic, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter.

FNA biopsy is becoming more common. In a study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011. This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with surgery did not rise in this same period. Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam.

Addressing indeterminate FNA results

As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two techniques to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test.

A meta-analysis of six studies of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies, but it did not do a good job of identifying those who did have cancer.

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign.

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid.

What is the significance of calcification?

Microcalcifications in the nodule can be detected with an ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients. This does not mean that a patient has malignancy with calcifications, but that there is a higher risk.

The ‘wait and follow-up’ approach

As I mentioned above, most thyroid nodules are benign. The results of one study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years. The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), the existence of multiple nodules, greater nodule volume at baseline, and being male.

The study authors’ suggestion is that, after the follow-up scan, the next ultrasound scan might be five years later instead of three. However, they did discover thyroid cancer in 0.3 percent after five years.

How does thyroid function affect outcomes?

In considering risk factors, it’s important to note that those who had normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (13).

Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. Why the mortality rate remains the same, year over year for decades, may have to do with the slow rate at which most thyroid cancers progress, especially of the two most common forms, follicular and papillary.

References:

(1) uptodate.com. (2) AACE 2013 Abstract 1048. (3) Thyroid. 2005;15(7):708. (4) European Thyroid Journal. 2022 Jun 29;11(4) online. (5) AACE 2013 Abstract 1048. (6) thyroid.org. (7) AAES 2013 Annual Meeting. Abstract 36. (8) AACE 2013 Abstract 1048. (9) Cancer. 2011;117(20):4582-4594. (10) J Clin Endocrinol Metab. Online May 12, 2015. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) J Clin Endocrinol Metab. 2006;91(11):4295.

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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