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Diet

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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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Much of our sodium comes from processed foods, including breads and sauces

By David Dunaief, M.D.

Dr. David Dunaief

When you hear someone tell you that you should lower your salt intake, how do you respond? Typically, I hear responses like, “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.”

Unfortunately, these are rarely true. All of us should be concerned about salt or, more specifically, our sodium intake. Also, approximately 90 percent of Americans consume too much sodium (1).

Why do we care?

We most often hear that excessive sodium in our diets increases the risk of high blood pressure (hypertension), which has consequences like stroke and heart disease.

Now comes the interesting part. Sodium also has a nefarious effect on the kidneys. In the Nurses’ Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it can be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

How much is too much?

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

Where does sodium hide?

If the salt shaker is not the problem, what is? Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out or ordering in on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of her clothes and rings being tight.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this. Excess sodium causes the body to retain fluids.

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. 

Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. 

Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Breads and rolls are another hidden source. Most contain a decent amount of sodium. I have seen a single slice of whole wheat bread include up to 200 mg. of sodium.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

What about sea salt?

Are fancy sea salts better than table salt? High amounts of salt are harmful, and the type is not important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly so, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.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. 

METRO photo
Diet choices trump exercise for weight loss

By David Dunaief, M.D.

Dr. David Dunaief

To quash guilt about Thanksgiving meal indiscretions, many of us will resolve to exercise to burn off the calories from this seismic meal and the smaller, calorically dense aftershock meals, whether with a vigorous family football game or with a more modest walk.

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 during the holidays and work it off later.

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

Let’s look at the evidence.

Exercise for 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 (55) 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. This was a preliminary study, so no definitive conclusions can be made.

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

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 15 percent, or one in seven, 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 3-5 (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; 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 it is important to enjoy the holidays, remember that food choices will have the greatest 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 during the holidays, but also focus on more nutrient-dense foods. At a minimum, strike a balance rather than eating purely calorically dense foods. You won’t be able to exercise them away.

References:

(1) uptodate.com. (2) J Strength Cond Res. Online Oct. 28, 2014. (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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By Matthew Kearns, DVM

I’ve always had trouble instituting New Year’s resolutions. Shortened daylight hours and colder weather make it sooooohhh difficult to get up early and exercise. I also instinctively look for starchy foods instead of fresh fruits and vegetables. Our pets face the same problems. 

Wild animals in colder climates slow down their metabolism and hibernate during winter months as temperatures drop and food becomes scarce. Domesticated dogs and cats are not so far removed from their wild ancestors that their own bodies react the same way. How do we avoid the inertia that inevitably sets in with winter weather?

The first thing is to keep an exercise routine in place. One of the few advantages of global warming is although temperatures drop, we don’t see as much snow and ice as in previous years. Sticking with daily walks helps keep their (and our) waistline at a manageable diameter. When the weather is not cooperating and our pets only go out long enough to do their business consider an indoor exercise routine. Rolling a ball to play fetch or using toys designed for cats to induce their stalking instincts are viable alternatives to playing outside. 

The second phase of our New Year’s resolutions is to take a closer look at calorie intake during colder months. I always recommend evaluating how many treats, rawhides, table scraps, etc. our pets receive. During the winter months we may need to decrease or eliminate these extras. 

I also see a lot of pets that gain weight the winter after they’ve been spayed or neutered and that can be difficult to take off again. Studies have shown that spaying and neutering dogs and cats does slow metabolism but, just because your pet was spayed or neutered does not mean that they will automatically become obese if we monitor their calorie intake and adjust properly. 

If we are exercising and reducing calories but not seeing a reduction in weight, it’s time to talk to our veterinarian about underlying disease. Glandular disorders such as underactive thyroid in dogs can lead to obesity and, without thyroid supplementation, no amount of diet and exercise will help them. Older dogs and cats frequently suffer from obesity secondary to arthritis. These pets exercise less because they are unable to move like when they were younger. 

Supplements and medications are available to help make them more comfortable and exercise more. Increased exercise and subsequent weight loss could reduce or eliminate medications (I recommend supplements lifelong).  

I hope this information is helpful in keeping our pets from gaining too much during the winter months. Now, onto my New Year’s resolution … UGH!!!

Dr. Kearns practices veterinary medicine from his Port Jefferson office and is pictured with his son Matthew and his dog Jasmine. Have a question for the vet? Email it to [email protected] and see his answer in an upcoming column.

Stocking the fridge with healthy foods is a great way to start off the New Year. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

It is now the second week in January, and most of us have made a New Year’s resolution – or many of them. You’ve taken the first step, but how do you increase the “stickiness factor,” a term used by Malcolm Gladwell in his book, “The Tipping Point”?

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

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

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

According to a study, people with the most self-control utilize the least amount of willpower, because they take a proactive role in minimizing temptation (1). Start by changing the environment in your kitchen.

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

Automaticity: Forming new habits

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

Lifestyle modification: Choosing a diet

U.S. News & World Report released its annual ranking of diets last week (3). Three of the diets highlighted include the DASH (Dietary Approach to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. These were the top three for heart health. The Mediterranean diet was ranked number one overall, and the DASH diet was ranked second. Both the Ornish and the DASH diets ranked in the top six. 

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

For instance, in a randomized crossover trial, which means patients, after a prescribed time, can switch to the more effective group, showed that the DASH diet is not just for patients with high blood pressure. The DASH diet was more efficacious than the control diet in terms of diabetes (decreased hemoglobin A1C 1.7 percent and 0.2 percent, respectively), weight loss (5 kg/11 lb vs. 2 kg/4.4 lb), as well as in HDL (“good”) cholesterol, LDL (“bad”) cholesterol and blood pressure (4). 

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

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

I will share one more tip: Take it day by day, rather than obsessing on the larger picture. Health and weight loss can – and should – go together.

References:

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

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.   

Diet and exercise are the first line of defense for those living with diabetes. Stock photo

Taking your blood pressure medications at night has beneficial effects

By David Dunaief, M.D.

Dr. David Dunaief

Not surprisingly, soda – with 39 grams of sugar per 12-ounce can – is associated with increased risk of diabetes. However, the drink with the lowest amount of sugar is wine, red or white. Even more surprising, it may have benefits in reducing complications associated with diabetes. Wine has about 1.2 grams of sugar in 5 ounces. Per ounce, soda has the most sugar, and wine has the least.

Why is this important? The prevalence of diabetes currently sits at 9.4 percent of the U.S. population, while another 84 million 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 had greater risk than men. In one 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). This was a retrospective (backward-looking) study.

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

Diet trumps drugs 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. While these are impressive results that speak to the use of lifestyle modification and to metformin, this is not the optimal diabetes diet.

Is wine really beneficial?

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 5 ounces of red wine, another 5 ounces of white wine, and the control group drank 5 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 on how 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.

Drugs (not diabetes drugs) show good 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 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 nonideal diet, in comparison to medication, had better results, though medication such as metformin could be used in high-risk patients that were having trouble following the diet. 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. 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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Reducing oxidative stress may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

Heart attacks and heart disease get a lot of attention, but chronic heart failure is often overlooked by the press. The reason may be that heart failure is not acute like a heart attack.

To clarify by using an analogy, a heart attack is like a tidal wave whereas heart failure is like a tsunami. You don’t know it’s coming until it may be too late. Heart failure is an insidious (slowly developing) disease and thus may take years before it becomes symptomatic. It also increases the risk of heart attack and death.

There are about 5.7 million Americans with heart failure, and experts project that will increase to 8 million by 2030 (1). Not surprisingly, incidence of heart failure increases with age (2).

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands and may decompensate. It is a complicated topic, for there are two types — systolic heart failure and diastolic heart failure. The basic difference is that the ejection fraction, the output of blood with each contraction of the left ventricle of the heart, is more or less preserved in diastolic HF, while it can be significantly reduced in systolic HF.

We have more evidence-based medicine, or medical research, on systolic heart failure. Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms may be similar, as well, and include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue. The risk factors for heart failure include diabetes, coronary artery disease, high blood pressure, obesity, smoking, heart attacks and valvular disease.

Typically, heart failure is treated with blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. We are going to look at how diet, iron and the supplement CoQ10 impact heart failure.

Effect of diet

If we look beyond the usual risk factors mentioned above, oxidative stress may play an important role as a contributor to HF. Oxidative stress is thought to potentially result in damage to the inner lining of the blood vessels, or endothelium, oxidation of cholesterol molecules and a decrease in nitric oxide, which helps vasodilate blood vessels.

In a population-based, prospective (forward-looking) study, called the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (3). 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. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

This nutrient-dense approach to diet increased oxygen radical absorption capacity. Oxygen radicals have been implicated in cellular damage and DNA damage, potentially as a result of increasing chronic inflammation. What makes this study so impressive is that it is the first of its kind to investigate antioxidants from the diet and their impacts on heart failure prevention.

This was a large study, involving 33,713 women, with good duration — follow-up was 11.3 years. There are limitations to this study, since it is an observational study, and the population involved only women. Still, the results are very exciting, and it is unlikely there is a downside to applying this approach to the population at large.

CoQ10 supplementation

Coenzyme Q10 is a substance produced by the body that helps the mitochondria (the powerhouse of the cell) produce energy. It is thought of as an antioxidant. 

Results of the Q-SYMBIO study, a randomized controlled trial, showed an almost 50 percent reduction in the risk of all-cause mortality and 50 percent fewer cardiac events with CoQ10 supplementation (4). This one randomized controlled trial followed 420 patients for two years who had severe heart failure. This involved using 100 mg of CoQ10 three times a day compared to placebo.

The lead author goes as far as to suggest that CoQ10 should be part of the paradigm of treatment. This the first new “drug” in over a decade to show survival benefits in heart failure. Thus, if you have heart failure, you may want to discuss CoQ10 with your doctor.

Iron deficiency

Anemia and iron deficiency are not synonymous, since iron deficiency can occur without anemia. A recent observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (5).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L.

The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients. Thus, it behooves us to try to prevent heart failure through dietary changes, including high levels of antioxidants, because it is not easy to reverse the disease. Those with HF should have their ferritin and iron levels checked, for these are correctable. 

I am not typically a supplement advocate; however, based on the latest results, CoQ10 seems like a compelling therapy to reduce risk of further complications and potentially death. Consult with your doctor before taking CoQ10 or any other supplements, especially if you have heart failure.

References:

(1) Card Fail Rev. 2017 Apr; 3(1):7–11. (2) J Am Coll Cardiol. 2003;41(2):21. (3) Am J Med. 2013 Jun:126(6):494-500. (4) JACC Heart Fail. 2014 Dec;2(6):641-649. (5) Am Heart J. 2013;165(4):575-582.

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 or consult your personal physician.     

A recent study suggests that drinking diet soda may increase the risk of heart disease. Stock photo
Simple dietary changes can improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Cardiovascular disease is anything but boring; what we know about it is constantly evolving. New information comes along all the time, which on the whole is a good thing. Even though cardiovascular disease has been on the decline, it is still the number one killer of Americans, responsible for almost 30 percent of deaths per year (1). However, not all studies nor all analyses on the topic are created equal. Therefore, I thought it apropos to present a quiz on cardiovascular disease myths and truths.

Without further ado, here is a challenge to your cardiovascular disease IQ. The questions below are either true or false. The answers and evidence are provided after.

1) Saturated fat is good for us, but processed foods and trans fats are unhealthy.

2) Fish oil supplements help reduce the risk of cardiovascular disease and mortality.

3) Fiber has significant beneficial effects on heart disease prevention.

4) Unlike sugary sodas and drinks, diet soda is most likely not a contributor to this disease.

5) Vitamin D deficiency may contribute to cardiovascular disease.

Now that was not so difficult. Or was it? The answers are as follows: 1-F, 2-F, 3-T, 4-F and 5-T. So, how did you do? Regardless of whether you know the answers, the reasons are even more important to know. Let’s look at the evidence.

Saturated fat

Most of the medical community has been under the impression that saturated fat is not good for us. We need to limit the amount we ingest to no more than 10 percent of our diet. But is this true? The results of a published meta-analysis (a group of 72 randomized clinical trials and observational studies) would upend this paradigm (2).

While saturated fat did not decrease the risk of cardiovascular disease, it did not significantly increase the risk either. Also, results showed that trans fats increase risk. Of course, trans fats are a processed fat, so this is something that most of us would agree upon. And in the clinical trials portion of the meta-analysis, omega-3 and omega-6 polyunsaturated fats did not significantly reduce the risk of cardiovascular disease.

Does this mean that we can go back to eating saturated fats with impunity? Well, there were weaknesses and flaws with this study. The authors only looked at the one dimension of fat. Their comparison was based on the upper-third of intake of one type of fat versus the lower-third of intake of the same type of fat (whether it was saturated fat or a type of unsaturated fat). It did not consider whether saturated fat was substituted with refined grains or unsaturated fatty acids. Also, what was the source of saturated fats, animal or plant, and did these sources also contain unsaturated fats as well, like olive oil or nuts which contain good fats?

Therefore, there are many unanswered questions and potentially several significant flaws with this study.

The meta-analysis also does not differentiate among plant or animal saturated fat sources. But in one that does, the researchers found saturated fats from animal sources increased cholesterol and the risk of cardiovascular disease (3). Also in another study, specifically using unsaturated fats in place of saturated fat reduced the risk of this disease (4, 5).

Fish oil

There is a whole industry built around fish oil and reducing the risk of cardiovascular disease. Yet the data don’t seem to confirm this theory. In the age-related eye disease study 2 (AREDS2), unfortunately, 1 gram of fish oil (long-chain omega-3 fatty acids) daily did not demonstrate any benefit in the prevention of cardiovascular disease nor its resultant mortality (6). This study was done over a five-year period in the elderly with macular degeneration. The cardiovascular primary end point was a tangential portion of the ophthalmic AREDS2. This does not mean that fish, itself, falls into that same category, but for now there does not seem to be a need to take fish oil supplements for heart disease, except potentially for those with very high triglycerides. Fish oil, at best, is controversial; at worst, it has no benefit with cardiovascular disease.

Fiber

We know that fiber tends to be important for a number of diseases, and cardiovascular disease does not appear to be an exception. In a meta-analysis involving 22 observational studies, the results showed a linear relationship between fiber intake and decreased risk for developing cardiovascular disease (7). In other words, for every 7 grams of fiber consumed, there was a 9 percent reduced risk in developing the disease. It did not matter the source of the fiber from plant foods; vegetables, grains and fruit all decreased the risk of cardiovascular disease. This did not involve supplemental fiber, like that found in Fiber One or Metamucil. To give you an idea about how easy it is to get a significant amount of fiber, one cup of lentils has 15.6 grams of fiber, one cup of raspberries or green peas has almost 9 grams, and one medium-size apple has 4.4 grams. Americans are sorely deficient in fiber (8).

Diet soda

A presentation at the American College of Cardiology examined the Women’s Health Initiative: The study suggests that diet soda may increase the risk of heart disease (9). In those drinking two or more cans per day, defined as 12 ounces per can, there was a 30 percent increased risk of a cardiovascular event, such as a stroke or heart attack, but an even greater risk of cardiovascular mortality, 50 percent, over 10 years. These results took into account confounding factors like smoking, diabetes, high blood pressure and obesity. This study involved over 56,000 postmenopausal women for almost a nine-year duration.

Vitamin D

The results of an observational study in the elderly suggest that vitamin D deficiency may be associated with cardiovascular disease risk. The study showed that those whose vitamin D levels were low had increased inflammation, demonstrated by elevated biomarkers including C-reactive protein (CRP) (10). This biomarker is related to inflammation of the heart, though it is not as specific as one would hope.

Beware in regards to saturated fat. If a study looks like an outlier or too good to be true, then probably it is. I would not run out and get a cheeseburger just yet. However, study after study has shown benefit with fiber. So if you want to reduce the risk of cardiovascular disease, consume as much whole food fiber as possible. Also, since we live in the Northeast, consider taking at least 1000 IUs of vitamin D daily. This is a simple way to help thwart the risk of the number one killer.

References:

(1) hhs.gov. (2) Ann Intern Med. 2014;160(6):398-406. (3) JAMA 1986;256(20):2623. (4) Am J Clin Nutr. 2009;99(5):1425-1432. (5) Cochrane Database Syst Rev. 2012:5;CD002137. (6) JAMA Intern Med. Online March 17, 2014. (7) BMJ 2013; 347:f6879. (8) Am J Med. 2013 Dec;126(12):1059-67.e1-4. (9) ACC Scientific Sessions 2014; Abstract 917-905. (10) J Clin Endocrinol Metab online February 24, 2014.

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 or consult your personal physician.

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Cheese, milk, butter, ice cream, yogurt. You were all such good friends. I was lucky to have known you at all.

Long ago, I developed an intolerance for you. It’s not as if you’d kill me but, let’s just say, you’d incapacitate me for a prolonged and agonizing period of time if I ever decided to ignore all the earlier experiences and indulge again.

That doesn’t mean, however, that I can’t appreciate the quality time we shared together, the memories you forever embedded in my taste buds and in my satisfied stomach.

I’ll start with the unexpected. Yes, you, in the corner, looking all innocuous. Stand up custardy yogurt and let me recall the smooth, cool feel and consistent taste. My favorite was banana, even though I lost the second-grade spelling bee when I thought there had to be an extra “n” in there somewhere. Someone with as many vowels as there are in the name Dunaief should have recognized the superfluous nature of consonants, but alas I was too young.

Then there’s macaroni and cheese. The soft noodles and almost too-sweet cheese was like a warm, sweet bath for my mouth. After throwing snowballs at my brothers or coming in from the walk along Mud Road from Gelinas on a rainy day, the hot mac and cheese revived me enough to break out my homework and try to figure how to find a second derivative or identify feldspar (a rock-forming mineral).

Then there’s that tall carton of milk. How awesome were you with Oreos and chocolate chip cookies? I’d dip the cookies deep into the milk, hoping they’d break apart. At the end of that refreshing glass, I’d have a blend of cookie crumbs supersaturated in milk at the bottom. I tipped the cool glass toward my mouth and let those mushy morsels land gently on my unfolded tongue.

And then there’s ice cream. After a movie at Stony Brook Loews, I’d sit with my buddies at Friendly’s on Route 347 and wait as patiently as I could for everyone else to figure out what they wanted. I pretended to read the menu, particularly when I was on a date and was considering what to say next, but the choice was always the same: the mint chocolate chip sundae.

During cold winter days, particularly after a day of skiing with my family — who were patient enough for me to stop getting frustrated when I fell, learn from my mistakes and enjoy the ride — I looked forward to onion soup. Oh, the melted cheese on the top of that soup. As my wife would say, what’s better than that?

Busboys risked serious injuries to their fingers if they tried to take the Crock-Pot before I’d finished picking every piece of cheese off the sides. When I finally looked up from my cheese removal operation, I saw my mom flashing that same annoying grin I show our children when I see how satisfied they are in a moment.

Since we’re discussing cheese, how about a grilled cheese? Buttered bread with soft American cheese was an irresistible delight. I’d order several of these sandwiches at the old Jack in the Box at the corner of 25A and Main Street in Setauket.

When I was young, one of my late father’s favorite sandwiches was Swiss cheese on rye with lettuce, tomato and mustard. The first time I tried it, I smiled politely and gave it back to him. Before the end of the dairy road for me, I ordered it again and thoroughly enjoyed it. Maybe it was an acquired taste or maybe it brought me closer to my father, who I could imagine enjoying the life and the food as much as I did. Oh, those dairy delights.

Stock photo.

By Chris Zenyuh

Throughout our evolution, fruit stood as the primary source of sugars in our diet. That we evolved to desire sweetness, I contend, was not for energy but for the vitamins, minerals, fiber and antioxidants that come with the fruit. The fiber helps slow sugar absorption and reduce its negative metabolic potential, and the vitamins compensate.

The limitations of seasonal fruit accessibility made getting too much of these sugars infrequent, at most. Access to purified cane sugar was limited as well, due its tropical origins. The cost of growing and shipping cane sugar slowed its consumption, certainly for those of lesser means. Still, the demand for sugar steadily increased, a fact that the English monarchy used to fund its war chest.

William Duffy (in his book “Sugar Blues”) has suggested that the sugar machine was largely behind English colonization and enslavement through the 1800s. Duffy suggests that denying sugar’s responsibility for metabolic dysfunction dates back to Dr. Thomas Willis, private physician to King Charles II. Willis both discovered and named diabetes mellitus. Smart enough to recognize the illness and its sugar-related cause, Willis was also smart enough to name it after “honey” instead of sugar, perhaps to keep his job and his head!

Enjoying rations of sugar and rum, tens of thousands of the British sailors who guarded the sugar routes fell ill and died from scurvy. School children are taught that scurvy is a vitamin C deficiency, as it was discovered that the symptoms could be reversed with the addition of citrus to the rations. Sadly, this well-known story promotes the denial of the cause: too much sugar (and rum). Our food, medical and supplement industries continue to promote the use of fortification and vitamin supplements to “protect” against illnesses like scurvy, rather than incur financial loses that would result from curtailed consumption of sugars.

The spiraling decline of our general health gained momentum in 1973, when then Secretary of Agriculture Earl Butz instituted a 180 degree change in the farm subsidy program. Prior to 1973, farmers were directed by the government to curtail production to keep the supply and demand for corn in check. Sometimes, the farmers were instructed not to grow corn but were compensated for lost income. The restricted supplies kept corn prices high, making it too expensive to use high fructose corn syrup as a sweetener. Sugar cane, expensive due to its tropical origins, found itself in a limited range of food products.

The new program launched in 1973 rewarded corn farmers for producing as much corn as possible. Soon, the science to produce more corn, then the science to engineer additional uses for the extra corn became big businesses. High fructose corn syrup and cattle feed businesses were early beneficiaries of the new system. The ranchers and corn refiners lobbied to pay below cost for corn. Corn farmers would lose money, but, the new farm bills enabled the farmers to make up their losses (and more) by receiving the subsidies, funded by tax dollars. That made it cheaper to feed cattle corn than to feed them grass and cheaper to sweeten food with high fructose corn syrup (HFCS) than with sugar.

Americans were now able to purchase foods sweetened with HFCS and corn-fed meat at much cheaper prices than ever before. The cost, of course, does not include the medical expenses that may be incurred from chronic exposure to glucose and fructose, though.

The Sugar Association, still burdened with the expense of sugar cane’s tropical origins, has expanded its use of sugar beets to become price competitive in the caloric sweetener market. Farmed and processed in the continental United States, sugar beets are used to sweeten processed foods almost as cheaply as HFCS. If the ingredient label doesn’t specify cane sugar, it may very well be beet sugar. Of course, it is still sucrose.

Now you know why caloric sweeteners are omnipresent in our food system and how “food” can be available so cheap. You might want to reconsider the amount that you consume of what nature so frugally offers. Regardless of its source or history, it is metabolically the same!

Chris Zenyuh is a science teacher at Harborfields High School and has been teaching for
30 years.