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Exercise is an inadequate weight-loss tool

By David Dunaief, M.D.

Dr. David Dunaief

We hear continuously about the importance of exercise. Why is it so important, though? Exercise has benefits for preventing and improving a wide range of medical conditions, from cardiovascular disease, chronic kidney disease, and diabetes to depression, insomnia, fatigue, balance, cognitive decline, and osteoporosis. Will it help you lose weight, though? While gym equipment ads emphasize this, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). It may only reduce fat mass and weight modestly for most people. It might, 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 out to compensate for that extra cookie.

Does exercise help with weight loss?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will promote weight loss. 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.

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, which is characterized as a moderately intense pace.

On the positive side, the women were in better aerobic shape by the study’s end. Also, women who had lost weight at four-weeks 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 exercise alone led to a disappointing amount of weight loss (4). In six months, patients lost a mean of 3.5 pounds, and at 12 months, they lost about 3.75 pounds.

A recent meta-analysis of aerobic exercise studies found that, in order to break through to meaningful reductions in waist circumference and body fat, participants had to exercise more than 150 minutes per week, up to 300 minutes weekly, at moderate to vigorous aerobic intensity (5).

However, 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 (6). In another study, when exercise was added to dietary changes, women were able to maintain 30 percent more weight loss than with diet alone after a year (7).

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects about 14 percent of U.S. adults, as one example of exercise’s impact on disease (8).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (9). When walkers were compared to non-walkers, walkers experienced a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death.

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 a week saw a 44 percent reduction in death and a 59 percent reduction in kidney replacement. This is significant. 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.

References:

(1) Diabetes Spectr. 2017 Aug;30(3):157–160. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) JAMA Netw Open. 2024;7(12):e2452185. (6) Obesity (Silver Spring). 2010;18(1):167. (7) Int J Obes Relat Metab Disord. 1997;21(10):941. (8) cdc.gov. (9) 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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Lifestyle modifications including diet can help

By David Dunaief, M.D.

Dr. David Dunaief

In my practice, many patients have resisted telling me they suffered from erectile dysfunction (ED). However, it’s a common problem. Because it can indicate other medical issues, it’s important that you share this information with your doctor.

ED affects about 24 percent of men, on average. If it occurs less than 20 percent of the time, it is considered normal; however, if it occurs more than 50 percent of the time, you should seek help (1). 

Of course, there are oral medications for ED. You’ve probably seen the ads for approved medications, including sildenafil (Viagra, or the “little blue pill”), tadalafil (Cialis), vardenafil (Levitra, Staxyn), and avanafil (Stendra). They work by causing vasodilation, or enlargement of blood vessels, which increases blood flow to the penis. Unfortunately, this does not solve the medical problem, but it does provide a short-term solution for those who are good treatment candidates.

ED’s prevalence generally increases with age. An analysis of the 2021 National Survey of Sexual Wellbeing found that ED affected 12.7 percent of 35-44-year-olds, increased to 25.3 percent of 45-54- year-olds, 33.9 percent of those aged 55-64, 48 percent of those aged 65-74, and 52.2 percent of those aged 75 and older (2).

So, what contributes to the increase as we age? Disease processes and drug therapies.

What is the connection between medical conditions and ED?

Chronic diseases can contribute significantly to ED. ED might also be an indicator of disease. Typical contributors include metabolic syndrome, diabetes, high blood pressure, cardiovascular disease and obesity. In the Look AHEAD trial, ED had a greater than two-fold association with hypertension and a three-fold association with metabolic syndrome (3). In another study, ED was associated with a 2.5-times increase in cardiovascular disease (4).

Patients with ED had significantly more calcification, or atherosclerosis, in their arteries when compared to a control group in a randomized clinical trial (RCT) (5). They were also more than three times as likely to have severe calcification. In addition, they had more inflammation, measured by C-reactive protein. 

Which medications contribute to ED?

About 25 percent of ED cases are thought to be associated with medications, such antidepressants, NSAIDs (e.g., ibuprofen and naproxen sodium), and hypertension medications. Unfortunately, the most common antidepressant medications, SSRIs, have significant impacts on ED. 

The California Men’s Health Study, with over 80,000 participants, showed that there was an association between NSAIDs and ED, with a 38 percent increase in ED in patients who use NSAIDs on a regular basis (6). The authors warn that patients should not stop taking NSAIDs without consulting their physicians.

Also, high blood pressure drugs have a reputation for causing ED. A meta-analysis of 42 studies showed that beta blockers have a small effect, but thiazide diuretics (water pills) more than doubled ED, compared to placebo (7).

How can diet affect ED?

The Mediterranean-type diet has been shown to treat and prevent ED. It’s a green leafy alternative to the little blue pill. Foods are rich in omega-3 fatty acids and high in monounsaturated fats and polyunsaturated fats, as well as fiber. Components include whole grains, fruits, vegetables, legumes, walnuts, and olive oil. 

In two RCTs lasting two years, those who followed a Mediterranean-type diet experienced improvements in their endothelial functioning (8, 9). They also experienced both lower inflammation and lower insulin resistance.

In another study, those who had the highest compliance with a Mediterranean-type diet were significantly less likely to have ED, compared to those with the lowest compliance (10). Even more impressive was that the group with the highest compliance had a 37 percent reduction in severe ED versus the low-compliance group.

A study of participants in the Health Professionals Follow-up Study looked closely at both the Mediterranean-type diet and the Alternative Healthy Eating Index 2010 diet, which emphasized consuming vegetables, fruits, nuts, legumes, and fish or other sources of long-chain fats, as well as avoiding red and processed meats (11). At this point, it probably won’t surprise you to hear that the greater participants’ compliance with either of these diets, the less likely they were to experience ED.

References:

(1) clevelandclinic.org. (2) J Sex Med. 2024;21(4): 296–303. (3) J Sex Med. 2009;6(5):1414-22. (4) Int J Androl. 2010;33(6):853-60. (5) J Am Coll Cardiol. 2005;46(8):1503. (6) Medicine (Baltimore). 2018 Jul;97(28):e11367. (7) JAMA. 2002;288(3):351. (8) Int J Impot Res. 2006;18(4):405-10. (9) JAMA. 2004;292(12):1440-6. (10) J Sex Med. 2010 May;7(5):1911-7. (11) JAMA Netw Open. 2020 Nov 2;3(11):e2021701.

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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By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

I’m sure you have a lot on your mind these days, with an abundance of Christmas requests and only a few remaining days to fill them.

My message is intended as a gift for you, not a request for myself. Your kindness and generosity toward others deserve to be returned. I am concerned about your growing belly, which has been compared to a bowl full of jelly when you laugh. Honestly, your upcoming journey around the world will likely make it worse. The cookies and milk, along with other sweets left for you on Christmas Eve, are only likely to make it worse.  

I’m concerned about your health and about the message it sends to kids. We’re currently dealing with an epidemic of overweight kids, which has contributed to the growing number of children with type 2 diabetes. According to the CDC, these numbers only get worse as children age.

You, Santa, can help reverse this trend and stem the increased risks of pancreatic cancer, breast cancer, liver cancer and heart disease that central belly fat promotes. Help children improve health outcomes that will follow them throughout their lives.

This is your opportunity to model the way — and, maybe fit back into that clingy tracksuit you’ve had in the back of your closet since the early 18th century, when you were still trim.

Think of the advantages of losing that extra weight. Your joints won’t ache as much in the cold; your back doesn’t hurt as much; and you will have more energy. Studies show that eating more fruits, vegetables and whole grains can reverse clogged arteries and help you avoid strokes, heart attacks and peripheral vascular disease. Even a simple change, like eating a small handful of raw nuts each day, can reduce your heart disease risk significantly.

Losing weight will also make it easier for you to keep your balance on steep, icy rooftops. No one wants you to take a tumble and break a 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 two. During the “offseason” you and the elves could train for the North Pole After Christmas 5k. Having a team to train with is much more fun.

If you add some weight training into your routine, you’ll strengthen your core. In addition, your new muscles will help melt away fat from your midsection.

It doesn’t have to be a chore. After all, who doesn’t love a game of tag with the reindeer? 

If you really want to make a strong start, 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 antioxidant qualities and can help reverse disease.

And, of course, don’t put candy in our stockings. We don’t need more sugar, and I’d guess that, over the long night, it’s hard to resist sneaking a few pieces, yourself. Why not reduce the temptation? This will also eliminate the sugar highs and lows you feel during your all-night expedition.

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

Think about giving athletic equipment, such as baseball gloves, soccer balls, 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 to each of the neighborhood chimneys.

The benefits of a healthier Santa will be felt across the world. Your reindeer won’t have to work as hard. You could 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 with nutrition and exercise. That’s the best gift you could give!

Wishing you good health in the coming year,

David

P.S. If it’s not too late to ask, I could use a bucket of baseballs and a new glove. I hear the Yankees have an opening for an outfielder, so I need to start 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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The DASH diet is a flexible eating plan that helps create a heart-healthy eating style for life. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. Unlike a heart attack, it develops slowly over years and may take a long time to become symptomatic. According to the latest statistics, 6.7 million Americans over the age of 19 are affected (1).  These numbers are projected to increase to 8.7 million by 2030, with the greatest growth among those aged 35 to 64 (2).

There are two types of heart failure, systolic and diastolic. Put simply, the difference is that the output of blood with each contraction of the heart’s left ventricle is generally preserved in diastolic HF, while it can be significantly reduced in systolic HF.

Fortunately, both types can be diagnosed with an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath during daily activities or when lying down; edema or swelling in the feet, legs, ankles or stomach, reduced exercise tolerance; and feeling tired or weak. These can have a significant impact on your quality of life.

Major lifestyle risk factors for heart failure include obesity, smoking, poor diet, being sedentary, excessive alcohol intake (3). Medical conditions that increase your risk include diabetes, coronary artery disease, high blood pressure, and valvular heart disease.

Heart failure can be treated with medication, including blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. All of these have side effects. We are going to look at recent studies that examine the role of diet in reducing your risk. 

The role of antioxidants in your diet

If we look beyond the risk factors mentioned above, some studies have explored the role oxidative stress may play an important role in contributing to HF.

In an analysis of the Swedish Mammography Cohort, researchers showed that a diet rich in antioxidants reduces the risk of developing HF (4). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. The antioxidants were mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for most of the effect.

This study was the first to investigate the impact of dietary antioxidants on heart failure prevention.

This was a large study: it involved 33,713 women with 11.3 years of follow-up. Still, there are limitations, because it was an observational study, and the population involved only women. However, the results are very exciting, and there is little downside to applying this approach.

Applying the DASH diet

A 2022 study examined the effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the risk of developing HF (5). This study included over 76,000 men and women, ages 45-83 and without previous HF, ischemic heart disease or cancer from the Cohort of Swedish Men and the Swedish Mammography Cohort.

The DASH diet emphasizes consuming fruit, vegetables, whole grains, nuts and legumes, and low-fat dairy and de-emphasizes red and processed meat, sugar-sweetened beverages, and sodium.

The researchers found that long-term adherence to the DASH diet was associated with a lower risk of HF. The greater the participants’ adherence, the greater the positive effect.

Interestingly, even replacing one serving per day of red and processed meat with one serving per day of other DASH diet foods was associated with an approximate 10 percent lower risk of HF.

Comparing a variety of diets

The REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (6). 

Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF. Compared with the lowest quartile, the highest quartile of adherence to the plant-based dietary pattern was associated with a 41 percent lower risk of HF. 

The highest adherence to the Southern dietary pattern was associated with a 72 percent higher risk of HF after adjusting for age, sex, and race and for other potential confounding factors. Researchers found less effect after further adjusting for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease.

They did not observe any associations with the other 3 dietary patterns.

These studies suggest that we should seek to prevent heart failure with dietary changes, including consuming higher amounts of antioxidant-rich foods, such as fruits and vegetables, and lower amounts of red and processed meats.

References:

(1) Circulation. 2024;149:e347–913. (2) hfsa.org. (3) cdc.gov. (4) Am J Med. 2013 Jun:126(6):494-500. (5) Eur J of Prev Cardiology 2022 May: 29(7): 1114–1123. (6) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045.

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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Dietary changes can reduce inflammatory factors

By David Dunaief, M.D.

Dr. David Dunaief

The common thread for more than 80 different autoimmune diseases is that the body’s immune system is attacking organs, tissues and cells and causing chronic inflammation (1). Type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, multiple sclerosis, Crohn’s disease, and inflammatory bowel disease are among the list of frequently occurring ones. Unfortunately, autoimmune diseases tend to cluster (2). This means that once you have one, you are at high risk for developing others.

Immunosuppressive therapies

Immunosuppressive therapies are the most prevalent treatment for autoimmune issues. As the name suggests, these reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors.

There are several concerning factors with these treatments.

First, they have substantial side effect profiles. They increase the risks for cancers, opportunistic infections and even death (3). Opportunistic infections can include diseases like tuberculosis and invasive fungal infections.

It makes sense that suppressing the immune system would increase the likelihood of infections. It’s also not surprising that cancer rates would increase, since the immune system helps fend off malignancies. One study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term clinical trials; however, many patients are prescribed these therapies for 20 or more years.

What other possibilities are there to treat autoimmune diseases? Studies are underway that test the efficacy of medical nutrition therapy using bioactive compounds and supplementation. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

Medical nutrition 

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including c-reactive protein (CRP), and improvements in joint pain and other quality of life issues.

What are the effects of fish oil?

Fish oil may help your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). A typical recommendation is to consume about 2 grams of EPA plus DHA to help regulate the immune system. Don’t take these high doses of fish oil without consulting your doctor, because fish oil can have blood-thinning effects.

Do probiotics help?

Approximately 70 percent of your immune system lives in your gut. Probiotics have immune-modulating effects that decrease inflammation by populating the gut with live beneficial microorganisms. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that have been shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Does increasing fiber help?

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one randomized controlled trial, 30 grams, or about one ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

Can diet reduce medication needs?

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Bioactive compounds found in high-nutrient foods and supplements can have a profound impact on your immune system’s regulation and may help reset the immune system. Even in severe cases, bioactive compounds in foods may work in tandem with medications to treat autoimmune diseases more effectively and help reduce dosing of some immunosuppressives, minimizing potential side-effects.

This is not hypothetical. I have seen these effects in my practice, where patients have been able to reduce – or even eliminate – immunosuppressives by altering their diets.

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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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By Leah S. Dunaief

Leah Dunaief

We seem to be living at a higher level of anxiety. Maybe not all of us. Somewhere there might be one or two souls who are still calmly oblivious to the world around us. Those are the ones who have turned off their televisions and radios, who don’t read newspapers and have put away their cellphones. But from conversations I have had, that’s not the rest of us. The rest of us are quietly, or not so quietly concerned.

What’s wrong? Let’s make a list. Better yet, let’s not. Instead, let’s think about how to cope.

One way to start is to divide what troubles us into two lists: those we can do something about and those we cannot. Then concentrate on the former. When confronted with hate, we can respond with kindness. We can listen rather than scream. We can do our tiny bit to help make our neighborhood a better place.

A psychotherapist I was interviewing recently told me she instructs her anxious clients to concentrate on their breathing, taking deep breaths for ten minutes to calm the body. The usual trio of eating, sleeping and exercising properly are critically important to maintain. Meditation, and even aromatherapy may also help. 

Specifically:

Exercise regularly. It’s good for both body and mind. One recent study revealed that “people with physically active lifestyles had about 60 percent lower risk of developing anxiety disorders,” according to healthline. This study was done over 21 years and followed 400,000 participants.

How does exercise work? For one, it provides a distraction from whatever is worrying. Also, getting the heart rate up changes brain chemistry, encouraging the secretion of anti-anxiety brain messengers like serotonin and gamma-aminobutyric acid (GABA). According to the American Psychological Association, “regular exercise leads to an enhancement of concentration and willpower, which can help certain anxiety symptoms.” 

Plus you feel good, especially when you stop. Walking is the simplest and perhaps most enjoyable way to exercise, particularly at this time of year, when it is not too hot nor too cold, and the changing colors of the foliage are a delight.

Eating a balanced diet, and eating it calmly, is important. Low blood sugar levels, dehydration and chemicals in processed foods, such as artificial flavorings, artificial coloring and preservatives can cause mood changes. A high-sugar diet can also have a negative reaction. So what should we eat? Fruits and vegetables, especially those leafy dark green ones rather than those high in starch, are ideal. After that, complex carbohydrates and beans, are a good source of nutrition. I happen to like fish, the white fleshy kind like sea bass, rather than lean meat, for animal protein. But remember, there is plenty of protein in veggies and beans.

Sleep is so important. A good night’s sleep leaves me feeling as if, the next day, I could “leap tall buildings at a single bound,” to borrow from the Superman tagline. Ah, but how to get a good night’s sleep? I am a good sleeper, and I will tell you what I do—most of the time.

I don’t watch television or use my computer or cellphone before going to bed. Something about that blue light wakes me up. I don’t even have those in my bedroom. I will sometimes read a bit, but not a page turner. My room is the coolest in the house, and I will frequently have the window open, even a tiny bit, in winter. I know that going to bed the same time each night is recommended, though I don’t always follow that advice. Also no alcohol before bedtime is also advised. It helps put me to sleep but I will be wide awake when the alcohol wears off in the middle of the night. And, I invested in a comfy down comforter years ago that, with its plushness, invites me into bed.

Better not to nap during the day, and that leaves me sufficiently tired by bedtime, especially if I have exercised. At least, it should. If it doesn’t, I will empty my thoughts onto a list, put the pad on the bedside table, then doze off.

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'I have seen very good results when treating patients who have eczema with dietary changes.- Dr. David Dunaief METRO photo
New treatments are evolving

By David Dunaief, M.D.

Dr. David Dunaief

If you have eczema, you’re familiar with its symptoms, which can include rashes, itching, pain and redness. What may not be as clear are its causes and potential implications.

Eczema is a chronic inflammatory process, and it’s likely caused by a combination of genetics and lifestyle choices (1).

While there is no cure, some treatments can ease symptoms and reduce flare-ups. These range from over-the-counter creams and lotions, antihistamines for itchiness, prescription steroid creams, oral steroids, and injectable biologics. Some sufferers use phototherapy for severe cases, but there’s not a lot of research suggesting this is effective. Interestingly, diet may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

How does diet affect eczema?

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (2).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet of those who were allergic, according to IgE testing, eczema improved significantly (3).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes many patients who suffer from some level of eczema. For example, a young adult had eczema mostly on his extremities. When we first met, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin improved significantly.

Do supplements help reduce eczema symptoms?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective. There are also some important concerns about them.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (4).

The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (5).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Are biologics a good alternative?

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (6). There are two currently approved by the FDA, dupilumab and tralokinumab.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like other monoclonal antibodies, they work by interfering with parts of your immune system. They suppress messengers of the white blood cells, called interleukins. This leaves a door open for side effects, like serious infections.

Does eczema affect bone health?

Several studies have examined the relationship between eczema and broken bones. One observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and a 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (7).

If you have both fatigue or insomnia in combination with eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that corticosteroids used in treatment could be one reason, in addition to chronic inflammation, which may also contribute to bone loss risk. 

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (8). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life. Supplements may not be the solution, at least not borage oil nor evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroids because of their long-term side effects. Diet adjustments appear to be very effective, at least at the anecdotal level.

References:

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) Allergy. 2010 Jun 1;65(6):758-765. (3) J Am Acad Dermatol. 2004;50(3):391-404. (4) Cochrane Database Syst Rev. 2013;4:CD004416. (5) mayoclinic.org (9) Medscape.com. (6) JAMA Dermatol. 2015;151(1):33-41. (7) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (8) nationaleczema.org.

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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We know better. So why can’t we do better?

By David Dunaief, M.D.

Dr. David Dunaief

We are continuously inundated with messages about the importance of including fruits and vegetables in our daily diets. In addition to fiber, they include critical nutrients and micronutrients that keep us healthy and reduce our risks of developing chronic diseases.

Despite this, according to a 2022 report by the Centers for Disease Control and Prevention (CDC), an average of 12.3 percent of U.S. adults met the daily requirements for fruit intake, and an even more abysmal 10 percent met vegetable intake recommendations (1). As you might expect, it follows that we are deficient in many key micronutrients (2).

Why do we care? Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients. 

Here’s a stunning statistic: more than 50 percent of American adults have a chronic disease, with 27 percent having more than one (3). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade and are currently at around 77 years old.

One indicator of nutrient intake that we can measure is carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. I measure these regularly, because they give me a sense of whether the patient might lack potentially disease-fighting nutrients. A high nutrient intake dietary approach can resolve the situation and increase both carotenoid and other critical nutrient levels.

Why focus on a high nutrient intake diet?

A high nutrient intake diet focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals — plant nutrients. Micronutrients are bioactive compounds found mostly in foods and in some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum of them is greater than their parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (4).

A 20 percent increase in diet scores, which indicated an improved quality of diet, was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent more than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large, prospective cohort study, where the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

How can diet improve your quality of life?

Quality of life is as important as longevity. Let’s examine some studies that consider the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (6). The authors attribute this effect, at least partially, to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. Each tablespoon of olive oil contains 120 calories, all of them fat. If you eat too much of even good fat, it can be counterproductive. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s.

In a case-control study that compared those with and without disease, high intake of antioxidants from food was associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), the leading cause of blindness in those 55 years or older (7). This was true even when participants had a genetic predisposition for the disease.

There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can improve our outcomes. With a focus on a high nutrient intake diet, we can improve life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. Morb Mortal Wkly Rep 2022;71:1–9. (2) cdc.gov/nutritionreport (3) cdc.gov. (4) N Engl J Med 2017; 377:143-153. (5) BMJ. 2009;338:b2337. (6) Neurology June 15, 2011. (7) Arch Ophthalmol. 2011;129(6):758-766.

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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Different dietary approaches may help modulate the immune system

By Dr. David Dunaief

Dr. David Dunaief

Autoimmune disease is when the body’s immune system attacks the organs, cells and tissues and causes chronic inflammation. However, this umbrella term refers to more than 80 different diseases (1). Some are familiar names, like type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, multiple sclerosis, and inflammatory bowel disease. Others, like Lambert-Eaton myasthenic syndrome and Cogan syndrome, are less well-known.

Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others. They disproportionately affect women, although men are also at risk.

Treating autoimmune diseases with meds

The primary treatment is immunosuppressives. In RA, for example, where there is swelling of joints bilaterally, a typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

However, there are several concerning factors with these drugs. First, the side-effect profiles are substantial. They includes risks of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning required by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

It is no surprise that suppressing the immune system would increase the likelihood of infections. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Second, these drugs were tested and approved using short-term clinical trials; however, many patients are prescribed these therapies for 20 or more years.

So, what other methods are available to treat autoimmune diseases? Medical nutrition therapy using bioactive compounds and supplementation are being studied. Medical nutrition therapy may have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression.

Managing inflammation with nutrition

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including c-reactive protein (CRP), and improvements in joint pain and other quality of life concerns.

Fish oil’s effects

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). A typical recommendation is to consume about 2 grams of EPA plus DHA to help regulate the immune system. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood-thinning effects.

Probiotic supplements

Approximately 70 percent of your immune system lives in your gut. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Increasing fiber intake

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and, potentially, autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high-nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects, treating and preventing autoimmune diseases.

References: 

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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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Moderate exercise is better for weight maintenance than weight loss

By David Dunaief, M.D.

Dr. David Dunaief

It’s that time of year again, when exercise product commercials flood the airways. If you have “lose weight” on your list of 2022 resolutions, it’s helpful to consider what the research tells us about the relationship between exercise and weight loss.

Unfortunately, exercise without dietary changes may not actually 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. However, it may be helpful with weight maintenance.

Ultimately, it may be more important to reconsider what you are eating than to succumb to the rationalization that you can eat with abandon and work it off later.

Don’t give up on exercise just yet, though. There is good news: Exercise does have benefits for a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.

Exercise may not result in weight loss

The well-known weight-loss paradigm is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. 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 — or, in other words, 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 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Exercise and weight maintenance

However, exercise may be valuable in 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 in a prospective study (6).

Exercise and disease

Walking the dog several times a week is a good moderate exercise. METRO Photo

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 15 percent of adults in the United States, according to the Centers for Disease Control and Prevention (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, stages 3 to 5 (8). Yes, this includes stage 3, which most likely is asymptomatic. 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 results were based on a dose-response curve. In other words, 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.

Therefore, while there are many benefits to exercise, food choices will have a greater impact on our weight and body composition. 

However, exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

So, by all means, exercise, but also focus on consuming nutrient-dense foods instead of calorically 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. 

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