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Diabetes

Lignans found in plants can reduce risk. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

It’s always surprising the number of myths that still circulate about type 2 diabetes, considering its prevalence in the U.S. Science is continually advancing what we know about diabetes risk and disease management, and some older interpretations deserve to be retired. Let’s take a look at a few common myths and the research that debunks them.

MYTH: Fruit should be limited or avoided.

Fruit, whether whole fruit, fruit juice or dried fruit, has been long considered taboo for those with diabetes. This is only partially true.

Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at 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. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

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

MYTH: All carbohydrates raise your sugars.

Fiber is one type of carbohydrate that has distinct benefits. We know fiber is important for reducing risk for a host of diseases and for managing their outcomes, and it is not any different for diabetes. 

In the Nurses’ Health Study (NHS) and NHS II, two very large prospective observational studies, plant fiber was shown to help 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 linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

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

MYTH: Soy should be avoided when you have diabetes.

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

This was a small randomized control trial over a four-year period with 41 participants. The control group’s diet consisted of 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 should be cautious or avoid soy since it may suppress thyroid functioning.

MYTH: Bariatric surgery is an alternative to lifestyle changes.

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 bariatric surgery involving 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time 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 remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintaining long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order 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) 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. 

METRO photo
Annual eye exams are crucial

By David Dunaief, M.D.

Dr. David Dunaief

Diabetic retinopathy is a frequent consequence of diabetes and is the number one cause of blindness in the U.S. among those 20 to 74 years old (1). Diabetic retinopathy (DR) is an umbrella term for microvascular complications of diabetes that can lead to blurred vision and blindness.

Among the risk factors for DR are diabetes duration, glucose (sugar) that is not well-controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2). As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (3). Herein lies the challenge, because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.

Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by extracellular fluid accumulating in the macula (4). The macula is the region of the eye with greatest visual acuity. An oval spot in the central portion of the retina, it is sensitive to light. When fluid builds up from leaking blood vessels, there is potential for vision loss.

Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (3).

In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (5). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse damage. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes.

Treatment options

While DME has traditionally been treated with lasers, intravitreal (intraocular — within the eye) injections of anti-VEGF medications may be more effective. These work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (6).

The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab (Lucentis), whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).

Some diabetes drugs increase risk

You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (8). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings of other significant issues.

To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.

This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both of these studies were not without weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (10). Thus, there needs to be more study done to sort out these results.

Glucose control and diet

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But an inference can be made: A nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (12, 13).

The best way to avoid diabetic retinopathy and DME is obviously to prevent diabetes. Barring that, it’s to have sugars well-controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones.

References:

(1) cdc.gov. (2) JAMA. 2010;304:649-656. (3) www.aao.org/ppp. (4) www.uptodate.com. (5) JAMA Ophthalmol. 2014;132:168-173. (6) Community Eye Health. 2014; 27(87): 44–46. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.

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. 

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Studies show that taking blood pressure medication at night lowers the risk of diabetes. METRO photo
Controlling sleep-time blood pressure may help

By David Dunaief, M.D.

Dr. David Dunaief

Our understanding of diabetes – its risks and treatment paradigms – is continually evolving. Because so many are affected by diabetes and prediabetes in the U.S., and because the potential health consequences, including significant cardiovascular risks, are so much greater in this population, studies frequently target this population.

To provide a sense of scale, the current rate of diabetes among the U.S. adult population is 13 per-cent, while another estimated 88 million U.S. adults have prediabetes, based on fasting glucose levels (HbA1C) of 5.7 to 6.4 percent (1).

For those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (2).

What may reduce risks of disease and/or complications? Fortunately, we are not without options. These include lifestyle modifications, timing of blood pressure medications, and, oddly, modest wine consumption.

Diet bests Metformin for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study, diet plus exercise bested metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were over-weight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, this is not an optimal diabetes diet.

Blood pressure medications’ timing

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (4). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys.

According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes.

Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.

Reducing complications with wine?

Diabetes patients are often warned to limit or eliminate alcohol. A significant part of the reasoning relates to how the body metabolizes alcohol and sugars. So, the results of a study that showed small amounts of wine could have benefits in reducing diabetes-associated complications among those who were well-controlled sent ripples throughout the medical community.

The CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (5).

Patients were randomized into three groups, each receiving a drink with dinner nightly. One group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good chomlesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Remember, participants were well-controlled type 2 diabetes patients who generally were nondrinkers.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a good, but nonideal, diet had better results than medication. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Diabetologia. Online Sept. 23, 2015. (5) Ann Intern Med. 2015;163(8):569-579.

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. 

METRO photo
Mouthwatering barbeque options can decrease health risks

By Daniel Dunaief

Dr. David Dunaief

What better way than the unofficial launch of summer holidays – and summer barbeques – to kick-start you on the path to preventing chronic diseases? In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are foods commonly found at barbeques and picnic meals. Therefore, I think it is only fair to talk about healthier alternatives and the evidence-based medicine that supports their benefits. The Mediterranean-style diet is a key to success. It is composed of thousands of beneficial nutrients that interact with each other in synergistic ways. 

The Mediterranean-style diet, as I have mentioned previous articles, includes green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of fish and olive oil. We all want to be healthier, but these are the summer holidays – doesn’t healthy mean tasteless? Not at all!

At a memorable family barbeque, we had a bevy of choices that were absolutely succulent. These included a three-bean salad, mandarin orange salad with mixed greens and a light raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon fillets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable shish kebobs, and large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence that explains why these foods help us.

Cancer prevention

Fruits and vegetables may help prevent pancreatic cancer. This is very important, since by the time there are symptoms, the cancer has spread to other organs and the patient usually has less than 2.7 years to live (1). Five-year survival is only five percent (2). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and non-citrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (3). Interestingly, cooked vegetables, not just raw ones, had a substantial effect.

Garlic plays an important role in reducing the risk of colon cancer. In the IOWA Women’s Health Study, a large prospective (forward-looking) trial involving 41,837 women, there was a 32 percent reduction in risk of colon cancer for the highest intake of garlic compared to the lowest. Vegetable consumption also showed a statistically significant reduction in the disease, as well (4). Many of my patients find that fresh garlic provides a wonderful flavor when cooking vegetables.

Diabetes – treatment and prevention

Fish plays an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of intake of fish and seafood had a substantial decrease in risk of type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood in potentially preventing the disease. Therefore, there is nothing wrong with some grilled fish on the “barbie” to help protect you from developing diabetes. 

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial (the gold standard of studies), mixed nuts led to a substantial reduction of hemoglobin A1C, a very important biomarker for sugar levels for the previous three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease.

The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke prevention

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial.

Though these are promising results, I caution you to use no more than one tablespoon of olive oil per day, since there are 120 calories in a tablespoon. 

It is not difficult to substitute the valuable Mediterranean-style diet for processed meats, or at least add them to the selection. This plant-based diet offers a tremendous number of protective elements in the prevention of many chronic diseases. So this Independence Day and beyond, plan to have on hand some mouth-watering healthy choices.

References:

(1) Nature. 2010;467:1114-1117. (2) Epidemiol Prev Anno 2007;31(Suppl 1). (3) Cancer Causes Control. 2010;21:493-500. (4) Am J Epidemiol. 1994 Jan 1;139(1):1-15. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-11. (7) Neurology. 2011 Aug 2;77(5):418-25.

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. 

rapes have been found to reduce glucose levels. Pexels photo
Whole berries may reduce glucose levels the most

By David Dunaief, M.D.

Dr. David Dunaief

Type 2 diabetes is pervasive throughout the population, affecting adults, but also children and adolescents. Yet, even with its prevalence, many myths persist about managing diabetes.

Among these are: Fruit should be limited or avoided; Soy has detrimental effects with diabetes; Plant fiber provides too many carbohydrates; and Bariatric surgery is an alternative to lifestyle changes.

All of these statements are false. My goal is to help debunk these type 2 diabetes myths. Let’s look at the evidence.

Fruit

Fruit, whether whole fruit, fruit juice or dried fruit, has been long considered taboo for those with diabetes. This is only partially true. Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at 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. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

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

Fiber

We know fiber is important for reducing risk for a host of diseases and for managing their outcomes, and it is not any different for diabetes. 

In the Nurses’ Health Study (NHS) and NHS II, two very large prospective observational studies, plant fiber was shown to help 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 linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

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

Soy and kidney function

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

This was a small randomized control trial over a four-year period with 41 participants. The control group’s diet consisted of 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 should be cautious or avoid soy since it may suppress thyroid functioning.

Bariatric surgery

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 bariatric surgery involving 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time 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 remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintaining long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order 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) 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. 

Phil O’Brien (left) and his brother Patrick show off their apperal company, Anchor East, with their slogan,’No suits, just sand.’ Photo by Julianne Mosher

Two Port Jefferson Station brothers used quarantine to create something special — a new clothing brand they’re calling Anchor East.

Phil and Patrick O’Brien are finalizing the unisex T-shirt, hoodie and hat brand that could create a community of people who love Long Island, by aligning their platform with several causes.

Photo by Julianne Mosher

Born and raised in Port Jeff Station, the family became integrated in the community, also owning O’Brien Insurance Agency on Main Street in the village. Phil, now an insurance agent, works out of the offices that his father started up there nearly 15 years ago. 

When the COVID-19 pandemic first hit in March, he was at home with a lot of free time. 

Like many throughout the COVID crisis, he decided to start dabbling in a hobby — graphic design.

He began throwing around ideas with his brother about things he always wanted to accomplish — one of them being to create an apparel brand.

“I wanted to make something that was a very local thing that all the locals know about,” he said. 

His brother, Patrick, got let go from his employer at the same time, so that’s when the two decided they could “make something good out of a bad situation.” They called Anchor East their passion project.

“We’ve always wanted to work together and now it was almost like we had a clean slate,” Phil said. “The way that everything came together was just so organic. He’s my best friend and having the opportunity to work together, while also giving back, is important to both of us.” 

It isn’t about making money, Phil said. They are choosing to give back to two different groups from the proceeds of their sales. 

Photo by Julianne Mosher

Growing up, Patrick was diagnosed with type 1 diabetes, so he knew that he’d want to donate to diabetes associations and research. 

“My entire life, the things that were important to me were the companies that would donate or do something in return, which back then obviously, wasn’t many,” he said. “So, us being able to create a company to do that for me and my story was crucial.”

But their charity doesn’t stop there. Both brothers grew up on the water, and are raising their kids there, too. They said they want Anchor East to become a movement, where people in the community can come together and clean up local beaches — like Pirate’s Cove, which they frequent with their family.

“We have this local company now that people can see,” Phil said. “We’re here to help and we want to give back. We want to clean up the local beaches because this is our home.”

They said they’d like for their beach cleanups to become an annual and well-known event every summer. They’re also hoping to open up a storefront for the brand Down Port. 

“I think that’s really important to us,” Phil said. “Being a part of the community, specifically Port Jeff, where we were born and raised.”

Patrick now lives in Coram. Phil is raising his family in Port Jeff Station, and his wife is a teacher at Port Jefferson high school. 

Photo by Julianne Mosher

“Between the beach cleanups and the diabetes associations that we want to work with, I think that we have something really special, and it’s something that we’ve talked about that we would love to give to our children one day,” Phil said. “We want them to see how important it is to give back when you’re in a position to do so.”

Patrick said that since they began the project early in quarantine, they haven’t stopped planning. 

“Doing something like this with my brother, someone who I trust and love more than anything in the world, with the mission that we have was an explosion,” he said. “We haven’t stopped since March.”

Their planning for Anchor East was full-speed ahead in July, when the duo spent the summer working on different designs and logos. On Jan. 18, they launched their social media accounts, teasing what merchandise would soon be released.

The brand’s website is now being finalized. Anchor East is expected to have a spring opening. 

“Showing people that we care, we want to clean up our beaches, take a step forward to make a difference, and to be able to give back to my disease which hundreds of thousands of people around the world are dealing with,” Patrick said, “We want to show them this is our mission and we’re not doing this for a paycheck. We’re doing it for the benefit of Long Island.”

Anchor East will be launching soon, but for now you can keep an eye out on their brand by following them on Instagram @AnchorEast or on Facebook.

Studies show that modest wine consumption may reduce cardiovascular risks. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

By now, we have all likely heard that soda – with 39 grams of sugar per 12-ounce can – is associated with an increased risk of diabetes. Bur did you know that wine has a very low amount of sugar: about 1.2 grams of sugar in a five-ounce serving? Even more surprising, it may have benefits in reducing complications associated with diabetes.

Why is this important? The current rate of diabetes among the U.S. adult population is 12.2 percent, while another 84 million U.S. adults have prediabetes (HbA1C of 5.7-6.4 percent) (1).

For those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (2).

What may reduce risks of disease and/or complications? Fortunately, we are not without options. These include timing of blood pressure medications, lifestyle modifications (diet and exercise) and, yes, wine.

Diet vs. metformin for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, this is not an optimal diabetes diet.

I’ll drink to that!

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (4).

Patients were randomized into three groups, each receiving a drink with dinner nightly; one group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Blood pressure medications’ surprising results

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (5). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a good, but nonideal, diet had better results, in comparison to medication. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Ann Intern Med. 2015;163(8):569-579. (5) Diabetologia. Online Sept. 23, 2015.

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. 

METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

We need help, and we need it fast. Not just for COVID-19, but also for diabetes, for the combination of the two is much worse than either disease alone. Type 2 diabetes can have devastating effects that can potentially result in patients dying prematurely from cardiovascular complications (1). COVID-19 symptoms can range from asymptomatic to severe or result in death.

Now combine diabetes with COVID-19 and you are at much higher risk of severe viral symptoms that require hospitalization and ICU admission. According to the CDC, about one-third ICU patients infected with COVID-19 have diabetes (2). 

Keeping patients out of the hospital

We know containment is critical to control COVID-19, but it’s equally important to get ahead of the mitigation of symptoms curve; we need to control the chronic diseases that exacerbate the virus’s severity. And Type 2 diabetes is one of the largest contributors. 

We can treat and reverse diabetes by empowering patients with lifestyle changes, especially diet. This is such an issue that the Mexican Deputy Minister of Health recently alluded to the fact that poor diet over at least the last 4 decades has resulted in more diabetes and obesity making people much more susceptible to COVID-19 and progressing to severe COVID-19 (3). 

It is tempting while staying at home for most of the day to want reach for comfort foods. Don’t do it. In fact, take the opposite approach and improve your diet. A whole food plant-based (WFPB) diet has been shown time and time again to prevent, treat and reverse diabetes potentially resulting in patients getting off their drugs and achieving levels that are considered normoglycemic, or non-diabetic. 

Let’s look at the evidence. 

Treating and reversing diabetes

Drugs help treat glucose, or sugar levels, and help reduce the risk of microvascular diseases such as diabetic retinopathy (eye disease causing blindness); nephropathy (kidney disease); and peripheral neuropathy, which can result in amputation. A few medications can even reduce macrovascular risk, or cardiovascular disease. Still, diet is still the best tool we have for reversing diabetes overall, with only beneficial side effects.

With COVID-19, those whose glucose is not under control are at highest risk of severe disease that results in a progression from hospitalization to ICU and the need for a ventilator to increased mortality risk. High sugars may have negative impacts on the white blood cells, which makes patients more susceptible to infection from viruses (4).

Medications’ impact

Diabetes medication alone can help control sugars, but it can’t reverse diabetes. In fact, studies with medication alone may actually increase the risk of death from polypharmacy, or too many medications. In the ACCORD trial, patients were put on an average of four diabetes medications. Researchers stopped the trial early after 3.5 years, because of a 22 percent increased rate of mortality (5). Patients did not reach their HbA1C (a three-month sugar reading) target of under 6.0 percent, because the increased death rate occurred at around 6.5. This was a large randomized controlled clinical trial with 10,251 patients, a mean age of 62.2 years, and mean HbA1C of 8.1 at baseline. 

Reversing Type 2 diabetes: plant-based dietary approach

On the other hand, studies with a WFPB diet, have shown significant reduction in sugars and potential reversal of diabetes. These include a small retrospective study and small randomized clinical trial comparing a WFPB diet to the American Diabetes’ (ADA) recommended diet. 

In a small retrospective study, the results showed a reduction of HbA1C from 8.2, which was a similar baseline as with the ACCORD trial, to 5.8 (6). Remember, the goal of the ACCORD trial was to get patients below a HbA1C of 6.0. These results occurred over a mean of seven months. In addition, patients were able to stop all of their diabetes medications and reduce their total number of medications from four to one.  The side effect was better health with a significant reduction in high blood pressure to normal levels, as well.

The weakness of this study was that it was retrospective (looking backward in time), only had 13 patients, and there was no control arm. However, it suggests that this type of diet is powerful to reduce and reverse type 2 diabetes. The foods used in the nutrient-dense WFPB diet included a non-starchy vegetable-rich approach, with an emphasis on dark green leafy vegetables, whole fruits, beans, and limiting grains, especially refined grains, and limiting starchy vegetables such as sweet potatoes, winter squashes, corn and pumpkin. 

In a larger study, results showed that a high fiber diet in patients with type 2 diabetes and hypertension significantly reduced HbA1C, fasting glucose, systolic (top number) blood pressure, branchial-ankle pulse wave velocity, serum cholesterol and waist-to-hip ratio, ultimately reducing the risk of cardiovascular disease (7). The participants were considered to be having high fiber if they increased their consumption 20-25 percent above recommended daily allowances. The fiber came from foods, not supplements, including vegetables, fruits, beans and whole grains. There were 200 participants over a six-month duration. 

A third study, which was a randomized controlled trial comparing the 2003 American Diabetes Association (ADA) diet to a low-fat vegan diet showed that a low-fat vegan diet significantly reduced the HbA1C compared to the 2003 ADA diet in a 74-week study (8). There were 99 type 2 diabetes patients in the study. A “side effect” of the low-fat vegan diet was that it also significantly reduced cholesterol. 

Preventing diabetes

There have been numerous studies demonstrating that a WFPB diet reduces the risk of diabetes. One of the best was the Adventist Health Study 2 (9). The results showed that a vegan diet reduced the risk of type 2 diabetes by 49 percent. This study is interesting because the different groups were very similar and it showed that small changes could have a big impact. Semi-vegetarians, pesco-vegetarians, and lacto-ovo vegetarians all had a reduced risk of diabetes compared to plant-focused non-vegetarians, but not as much as vegans. 

In a more recent study, results showed a 30 percent reduction in the risk of type 2 diabetes for those who ate a predominantly whole food plant-based diet including fruits, vegetables and whole grains (10). Participants were still eating some animal protein daily. This was over a 2-to-28 year period in a metanalysis involving nine observational trials.

In conclusion, the best way to reduce your risk of severe COVID-19 is to control and reverse chronic disease. Type 2 diabetes is one of the most common chronic diseases that may contribute to getting COVID-19 and progressing to a severe form. A nutrient-dense WFPB diet has been shown to potentially reverse type 2 diabetes. While you are mostly housebound, empower yourself by taking action to reduce your risk of getting COVID-19 and especially the severe disease. We have the tools: it starts with what you put on your plate.

References:

(1) Lancet 389(10085):2239–2251. (2) CDC.gov. (3) Reuters.com April 4, 2020. (4) Medscape.com March 18, 2020. (5) NEJM 2008;358:2545-2559. (6) OJPM 2012;2(3):364-371. (7) ACC Middle East Conference 2019 Presentation. (8) Am J Clin Nutr.2009 May; 89(5): 1588S–1596S. (9) Diabetes Care. 2009;32:791–796. (10) JAMA Int. Med. Online July 22, 2019.

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

Studies have shown that eating fresh fruit and cinnamon may be beneficial to diabetics. Stock photo
Fresh fruit and cinnamon may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

What causes Type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 12.2 percent of the U.S. population aged 18 or older has Type 2 diabetes, and about 9.4 percent when factoring all ages (1).

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

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

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of Type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage, however, we are talking about the overall prevalence, which is around 9.4 percent in the U.S., as we noted above.

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

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

Effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — Type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

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

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

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have Type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat Type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However, it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

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

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make lifestyle changes. So America, take an active role.

References:

(1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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

Walking for a five-minute duration every 30 minutes can reduce the risk of diabetes. Stock photo
Screening guidelines still miss 15 to 20 percent of cases

By David Dunaief, M.D.

Dr. David Dunaief

Finally, there is good news on the diabetes front. According to the Centers for Disease Control and Prevention, the incidence, or the rate of increase in new cases, has begun to slow for the first time in 25 years (1). There was a 20 percent reduction in the rate of new cases in the six-year period ending in 2014. This should help to brighten your day. However, your optimism should be cautious; it does not mean the disease has stopped growing. It means it has potentially turned a corner in terms of the growth rate, or at least we hope. This may relate in part to the fact that we have reduced our consumption of sugary drinks like soda and orange juice.

Get up, stand up!

It may be easier than you think to reduce the risk of developing diabetes. Standing and walking may be equivalent in certain circumstances for diabetes prevention. In a small, randomized control trial, the gold standard of studies, results showed that when sitting, those who either stood or walked for a five-minute duration every 30 minutes, had a substantial reduction in the risk of diabetes, compared to those who sat for long uninterrupted periods (2).

There was a postprandial, or postmeal, reduction in the rise of glucose of 34 percent in those who stood and 28 percent reduction in those who walked, both compared to those who sat for long periods continuously in the first day. The effects remained significant on the second day. A controlled diet was given to the patients. In this study, the difference in results for the standers and walkers was not statistically significant.

The participants were overweight, postmenopausal women who had prediabetes, HbA1C between 5.7 and 6.4 percent. The HbA1C gives an average glucose or sugar reading over three months. The researchers hypothesize that this effect of standing or walking may have to do with favorably changing the muscle physiology. So, in other words, a large effect can come from a very small but conscientious effort. This is a preliminary study, but the results are impressive.

Do prediabetes and diabetes have similar complications?

Diabetes is much more significant than prediabetes, or is it? It turns out that both stages of the disease can have substantial complications. In a study of those presenting in the emergency room with acute coronary syndrome (ACS), those who have either prediabetes or diabetes have a much poorer outcome. ACS is defined as a sudden reduction in blood flow to the heart, resulting in potentially severe events, such as heart attack or unstable angina (chest pain).

In the patients with diabetes or prediabetes, there was an increased risk of death with ACS as compared to those with normal sugars. The diabetes patients experienced an increased risk of greater than 100 percent, while those who had prediabetes had an almost 50 percent increased risk of mortality over and above the general population with ACS. Thus, both diabetes and prediabetes need to be taken seriously. Sadly, most diabetes drugs do not reduce the risk of cardiac events. And bariatric surgery, which may reduce or put diabetes in remission for five years, did not have an impact on increasing survival (3).

What do the prevention guidelines tell us?

The United States Preventive Services Task Force (USPSTF) renders recommendations on screening for diseases. In 2015, the committee drafted new guidelines suggesting that everyone more than 45 years old should be screened, but the final guidelines settled on screening a target population of those between the ages of 40 and 70 who are overweight or obese (4). They recommend that those with abnormal glucose levels pursue intensive lifestyle modification as a first step.

This is a great improvement, as most diabetes patients are overweight or obese; however, 15 to 20 percent of diabetes patients are within the normal range for body mass index (5). So, this screening still misses a significant number of people.

Potassium’s effect

When we think of potassium, the first things that comes to mind is bananas, which do contain a significant amount of potassium, as do other plant-based foods. Those with rich amounts of potassium include dark green, leafy vegetables; almonds; avocado; beans; and raisins. We know potassium is critical for blood pressure control, but why is this important to diabetes?

In an observational study, results showed that the greater the exertion of potassium through the kidneys, the lower the risk of cardiovascular disease and kidney dysfunction in those with diabetes (6). There were 623 Japanese participants with normal kidney function at the start of the trial. The duration was substantial, with a mean of 11 years of follow-up. Those who had the highest quartile of urinary potassium excretion were 67 percent less likely to experience a cardiovascular event or kidney event than those in the lowest quartile. The researchers suggested that higher urinary excretion of potassium is associated with higher intake of foods rich in potassium.

Where does this leave us for the prevention of diabetes and its complications? You guessed it: lifestyle modifications, the tried and true! Lifestyle should be the cornerstone, including diet and at least mild to moderate physical activity.

References:

(1) cdc.gov. (2) Diabetes Care. online Dec. 1, 2015. (3) JAMA Surg. online Sept. 16, 2015. (4) Ann Intern Med. 2015;163(11):861-868. (5) JAMA. 2012;308(6):581-590. (6) Clin J Am Soc Nephrol. online Nov 12, 2015.