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Dr. David Dunaief

By focusing on developing heart-healthy habits, we can improve the likelihood that we will be around for a long time. METRO photo
Modest dietary changes can have a big impact

By David Dunaief, M.D.

Dr. David Dunaief

With all of the attention on infectious disease prevention these past two years, many have lost sight of the risks of heart disease. Despite improvements in the numbers in recent years, heart disease in the U.S., making it the leading cause of death (1).

I have good news: heart disease is on the decline in the U.S. due to a number of factors, including better awareness, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. It still underpins one in four deaths, and it is preventable.

Manage your baseline risks

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

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

Another potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (4). A normal resting heart rate is usually between 60 and 100 bpm. Thus, you don’t have to have a racing heart rate, just one that is high-normal. All of these risk factors can be overcome.

How does medication lower heart disease risk?

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

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

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

Unfortunately, many on statins also suffer from myopathy (muscle pain). I have had a number of patients who have complained of muscle pain and cramps. Their goal is to reduce and ultimately discontinue their statins by following a lifestyle modification plan involving diet and exercise. Lifestyle modification is a powerful ally.

What lifestyle changes help minimize heart disease?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). 

The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required a modest change in diet.

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

How can you monitor your heart disease risk?

To monitor your progress, cardiac biomarkers are telling, including inflammatory markers like C-reactive protein, blood pressure, cholesterol and body mass index. 

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

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

By focusing on developing heart-healthy habits, we can improve the likelihood that we will be around for a long time.


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

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

For people who suffer from seasonal allergies, life is about to get really uncomfortable. METRO photo
Over the counter medications help some sufferers

By David Dunaief, M.D.

Dr. David Dunaief

This past weekend, we adjusted our clocks for Daylight Saving Time, the unofficial end of winter. Because it’s been warmer than usual this winter, I’ve noticed crocuses and daffodils are already sprouting and we’re just a few weeks out from full scale tree buds.

For people who suffer from seasonal allergic rhinitis, hay fever, seasonal allergies or whatever you would like to call it, life is about to get really uncomfortable. Just over 25 percent of U.S. adults were diagnosed with seasonal allergies in 2021, and 18.9 percent of children were diagnosed, according to the Centers for Disease Control and Prevention (1). The triggers for seasonal allergies are diverse. They include pollen from leafy trees and shrubs, grass and flowering plants, as well as weeds, with the majority from ragweed (mostly in the fall) and fungus (summer and fall) (2).

What triggers allergic reactions? 

A chain reaction occurs in seasonal allergy sufferers. When foreign substances such as allergens (pollen, in this case) interact with immunoglobulin E (IgE), antibodies that are part of our immune system, they cause mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response.

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it emulates a cold, but without the virus. If symptoms last more than 10 days and are recurrent, then it is likely you have allergies, not a virus.

If allergic rhinitis is not treated properly, you can experience complications like ear infections, sinusitis, irritated throat, insomnia, chronic fatigue, headaches and even asthma (4).

What medications help? 

The best way to treat allergy attacks is to prevent them, but this is can mean closing yourself out from the enjoyment of spring by literally closing the windows, using the air-conditioning, and using recycling vents in your car.

On the medication side, we have intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops, and leukotriene modifiers (second-line treatment only).

The guidelines for treating seasonal allergic rhinitis with medications suggest that intranasal corticosteroids (steroids) should be used when quality of life is affected. If there is itchiness and sneezing, then second-generation oral antihistamines may be appropriate (5). Two well-known inhaled steroids are Nasacort (triamcinolone) and Flonase (fluticasone propionate). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day and can have side effects, like headaches.

Oral antihistamines, on the other hand, can be taken on an as-needed basis. Second-generation antihistamines, such as loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra), have less sleepiness as a side effect than first-generation antihistamines, but don’t work for everyone.

Alternative treatments

 Butterbur (Petasites hybridus), an herb, has several small studies that indicate its efficacy in treating hay fever. In one randomized controlled trial (RCT) involving 131 patients, results showed that butterbur was as effective as cetirizine (Zyrtec) (6).

In another RCT, results showed that high doses of butterbur — 1 tablet given three times a day for two weeks — was significantly more effective than placebo (7). Researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) in the trial.

A post-marketing follow-up study of 580 patients showed that, with butterbur Ze339, symptoms improved in 90 percent of patients with allergic rhinitis over a two-week period (8). Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the population.

The caveats to the use of butterbur are several. First, the studies were short in duration. Second, the leaf extract used in these studies was free of pyrrolizidine alkaloids (PAs). This is very important, since PAs may not be safe. Third, the dose was well-measured, which may not be the case with over-the-counter extracts. Fourth, there are interactions with some prescription medications.

Treating allergies with diet?

While there are no significant studies on diet, there is one review of literature that suggests that a plant-based diet may reduce symptoms of allergies, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma. This is according to the International Study of Asthma and Allergies in Childhood study in 13- to 14-year-old teens (9). In my clinical practice, I have seen patients who suffer from seasonal allergies improve and even reverse the course of allergies over time with a vegetable-rich, plant-based diet, possibly due to its anti-inflammatory effect. Analogously, some physicians suggest that their patients have benefited from removing dairy from their diets.

While allergies can be miserable, there are a significant number of over-the-counter and prescription options to help reduce symptoms. Diet may play a role in the disease process by reducing inflammation, although there are no formal studies. There does seem to be promise with some herbs, like butterbur. However, alternative supplements and herbs lack large, randomized clinical trials with long durations. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.


(1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) J Allergy Clin Immunol. 2003 Dec;112(6):1021-31.. (4) J Allergy Clin Immunol. 2010 Jan;125(1):16-29.. (5) Otolaryngol Head Neck Surg. 2015 Feb;2:197-206. (6) BMJ 2002;324:144. (7) Arch Otolaryngol Head Neck Surg. 2004 Dec;130(12):1381-6. (8) Adv Ther. Mar-Apr 2006;23(2):373-84. (9) Eur Respir J. 2001;17(3):436-443.

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.

Image from METRO
Micronutrient deficiency and obesity are intertwined

By David Dunaief, M.D.

Dr. David Dunaief

If you’re trying to lose weight, you’re probably closely watching your calorie intake. We’ve been trained for a lifetime to scrutinize calories and to exercise more willpower in avoiding high-calorie options.

However, the road to weight loss, or even weight maintenance, is complex. Many things influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

Awareness of a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or can encourage higher calorie purchases (1, 2).

The good news is that success is not solely about willpower. Instead, we need to change our diet composition.

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

What is the impact of refined carbohydrates?

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

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

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

Do macronutrients matter?

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

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

Again, focusing primarily on macronutrient levels and calorie counts did very little to improve results.

What’s the relationship between micronutrients and weight?

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

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

How do cortisol levels affect health?

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

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

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


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

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

METRO photo
              The microbiome may have an impact on susceptibility to autoimmune diseases

By David Dunaief, M.D.

Dr. David Dunaief

Every human carries in its body a microbiome, consisting of bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, and much of it is still only loosely understood. What we do know, however, is that these trillions of microorganisms have key roles in our healthy functioning.

The microbiome is found throughout our bodies, including the skin, the eyes and the gut. Here, we’re going to focus on the gut, where the majority of our microbiome resides. The microbiome has been getting a lot of attention of late, because of its possible role in preventing and promoting diseases. Among these are obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

The Human Microbiome Project

Like the Human Genome Project, which mapped our genes, the Human Microbiome Project, funded by the National Institutes of Health from 2007 to 2016, sought to map and sequence the composition and diversity of these gut organisms and to prompt future research. Already, there have been some enlightening preliminary studies.

What affects the microbiome?

Drugs, such as antibiotics, can wipe out microbial diversity, at least in the short term. Also, lifestyle modifications, such as diet, can have a positive or negative impact. Microbiome diversity also may be significantly different in distinct geographic locations throughout the world.

The microbiome and obesity

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

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

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

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

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

This suggests that gut bacteria diversity may be a crucial piece of the weight-loss puzzle.

Rheumatoid arthritis

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

Can you counteract antibiotics’ negative effects?

Many have gastrointestinal upset while taking antibiotics, because antibiotics don’t differentiate between good and bad bacteria when they go to work. 

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

Although nobody can say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, seem to be important to the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. The research is continuing, but we’ve learned a lot already that may help us tackle obesity and autoimmune disorders.


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

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

Sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques linked to Alzheimer's disease. METRO photo
A few extra ZZZs can help clear brain clutter

By David Dunaief, M.D.

Dr. David Dunaief

Cognitive loss, or mental decline, is a common concern as we age. So much so that a cottage industry of app-based games has sprouted to help keep our brains sharp.

What do we know about the brain, really, though? Startlingly little. We do know that certain drugs, head injuries and lifestyle choices have negative effects, along with numerous neurological, infectious, and rheumatologic disorders and diseases.

Some, like dementia, Parkinson’s, and strokes, are recognized for some of their effects on the brain. However, others – lupus, rheumatoid arthritis, psychiatric mood disorders, diabetes and heart disease – also can have long-term effects on our brains.

These disorders generally have three signs and symptoms in common: they cause either altered mental status, physical weakness, or mood changes — or a combination of these.

Of course, addressing the underlying medical disorder is critical. Fortunately, several studies also suggest that we may be able to help our brains function more efficiently and effectively with rather simple lifestyle changes: sleep, exercise and possibly omega-3s.

How does brain clutter affect us?

Are 20-somethings sharper and more quick-witted than those over 60?

German researchers put this stereotype to the test and found that educated older people tend to have a larger mental database of words and phrases to pull from since they have been around longer and have more experience (1). When this is factored into the equation, the difference in terms of age-related cognitive decline becomes negligible.

This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something.

What if we could reboot our brains, just like we do a computer or smartphone? This may be possible through sleep, exercise and omega-3s.

Why does sleep help?

Why should we dedicate a large chunk of our lives to sleep? Researchers have identified a couple of specific values we receive from sleep: one involves clearing the mind, and another involves productivity.

For the former, a study done in mice shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (2). When we have excessive plaque buildup in the brain, it may be a sign of Alzheimer’s. When mice were sleeping, the interstitial space (the space between brain gyri, or structures) increased by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough, because cerebrospinal fluid could reach much farther into the spaces. A similar effect was seen when the mice were anesthetized.

In an Australian study, results showed that sleep deprivation may have contributed to an almost one percent decline in gross domestic product (3). Why? When people don’t get enough sleep, they are not as productive. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness on short-term basis, we can’t do this continually.

According to the Centers for Disease Control and Prevention, 4.2 percent of respondents reported having fallen asleep in the prior 30 days behind the wheel of a car during a 2009-2010 study (4). Most commonly, these respondents also reported getting usual sleep of six hours or fewer, snoring, or unintentionally falling asleep during the day. “Drowsy driving” led to 91,000 car crashes in 2017, according to estimates from the National Highway Traffic Safety Administration (5).

How does exercise help your brain?

One study with rats suggests that a lack of exercise can cause unwanted new brain connections. Rats that were not allowed to exercise were found to have rewired neurons around their medulla, the part of the brain involved in breathing and other involuntary activities. This included more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (6). 

Among the rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart. We need human studies to confirm this impact.

Omega-3 fatty acids may affect brain volume

In the Women’s Health Initiative Memory Study of Magnetic Resonance Imaging Study, results showed that those postmenopausal women who were in the highest quartile of omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (7). The hippocampus is involved in memory and cognitive function.

Specifically, the researchers looked at the levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes. The source of the omega-3 fatty acids could have been either from fish or from supplementation.

It’s never too late to improve brain function. Although we have a lot to learn about the functioning of the brain, we know that there are relatively simple ways we can positively influence it.


(1) Top Cogn Sci. 2014 Jan.;6:5-42. (2) Science. 2013 Oct. 18;342:373-377. (3) Sleep. 2006 Mar.;29:299-305. (4) cdc.gov. (5) nhtsa.gov. (6) J Comp Neurol. 2014 Feb. 15;522:499-513. (7) Neurology. 2014;82:435-442.

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.

Aquatic exercise can improve balance, strength and mobility. METRO photo
Simple exercises can help

By David Dunaief, M.D.

Dr. David Dunaief

We have had far more ice this winter than snow. Of particular concern is black ice, when a thin ice coating looks innocuously like a simple damp surface. This phenomenon has increased our risk for falling and injuring ourselves. I’ve received quite a few calls this winter from friends and patients who have taken tumbles resulting in broken bones and torn ligaments.

Even without icy steps and walkways, falls can be serious for older patients, where the consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability and a decline in physical and social activities (1). Ultimately, a fall can lead to loss of independence (2).

What increases fall risk?

There are many factors. A personal history of falling in the recent past is the most prevalent. However, there are other significant factors, such as age and medication use. Some medications, like antihypertensive medications, which are used to treat high blood pressure, and psychotropic medications, which are used to treat anxiety, depression and insomnia, are of particular concern. Chronic diseases can also contribute. Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (3).

Simple ways to reduce fall risk

It is most important to exercise. We mean exercises involving balance, strength, movement, flexibility and endurance, all of which play significant roles in fall prevention (4). The good news is that many of these can be done inside with no equipment or with items found around the home. We will look more closely at the research. 

Nonslip shoes are crucial indoors, and footwear that prevents sliding on winter ice, such as slip-on ice cleats that fit over your shoes, is a must. In the home, inexpensive changes, like securing area rugs, removing other tripping hazards, and adding motion-activated nightlights can also make a big difference.

Does your medication put you at risk?

There are several medications that heighten fall risk. Psychotropic drugs top the list, but what other drugs might have an impact?

A well-designed study showed an increase in fall risk in those who were taking high blood pressure medication (5). Those on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase.

These medications can reduce significantly the risks of cardiovascular disease and events, so physicians need to consider the risk-benefit ratio in older patients before stopping a medication. We also should consider whether lifestyle modifications, which play a significant role in treating this disease, can be substituted for medication (6).

The value of exercise

A meta-analysis showed that exercise significantly reduced the risk of a fall (7). It led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in falls requiring medical attention. Even more impressive was a 61 percent reduction in fracture risk.

Remember, the lower the fracture risk, the more likely you are to remain physically independent. The author summarized that exercise not only helps to prevent falls but also fall injuries.

Unfortunately, those who have fallen before, even without injury, often develop a fear that causes them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased fall risk (8).

What types of exercise are best?

Any consistent exercise program that improves balance, flexibility, and muscle tone and includes core strengthening can help improve your balance. Among those that have been studied, tai chi, yoga and aquatic exercise have all been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (9). The aim of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the overall number of falls and a 44 percent decline in the number of exercising patients who fell during the six-month trial, with no change in the control group.

If you don’t have a pool available, tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (10).

Another pilot study used modified chair yoga classes with a small assisted living population (11). Participants were those over 65 who had experienced a recent fall and had a resulting fear of falling. While the intention was to assess exercise safety, researchers found that participants had less reliance on assistive devices and three of the 16 participants were able to eliminate their use of mobility assistance devices.

Our best line of defense against fall risk is prevention with exercise and reducing slipping opportunities. Should you stop medications? Not necessarily. If you are 65 and older, or if you have arthritis and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before you consider changing your blood pressure medications, review your risk-to-benefit ratio with your physician.


(1) MMWR. 2014; 63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) JAMA. 1995;273(17):1348. (4) Cochrane Database Syst Rev. 2012;9:CD007146. (5) JAMA Intern Med. 2014 Apr;174(4):588-595. (6) JAMA Intern Med. 2014;174(4):577-587. (7) BMJ. 2013;347:f6234. (8) Age Ageing. 1997 May;26(3):189-193. (9) Menopause. 2013;20(10):1012-1019. (10) Mater Sociomed. 2018 Mar; 30(1): 38–42. (11) Int J Yoga. 2012 Jul-Dec; 5(2): 146–150.

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.

Vitamin D supplement
Obesity can reduce the benefits of supplementation

By David Dunaief, M.D.

Dr. David Dunaief

Here in the Northeast, it’s the time of year when colder temperatures mean we’re spending lots of time indoors. When we are outside, we cover most of our skin to protect us from the cold. This means we’re not getting a lot of sun. While this will make your dermatologist happy, it also means you’re probably not converting that sun exposure to vitamin D3.

There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of a treatment regimen. However, many questions remain.

Many of us receive food-sourced vitamin D from fortified packaged foods, where vitamin D has been added. This is because sun exposure — even under the best of circumstances — will not address all of our vitamin D needs. For example, in a study of Hawaiians, a subset of the study population who had more than 20 hours of sun exposure without sunscreen per week, some participants still had low vitamin D3 values (1).

We know vitamin D’s importance for bone health, but we have mixed data for other diseases, such as cardiovascular, autoimmune and skin diseases and cancer.

There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends between 20 and 50 ng/ml, and The Endocrine Society recommends at least 30 ng/ml.

Are there cardiovascular benefits to vitamin D?

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. The Framingham Offspring Study showed that those patients with deficient levels were at increased risk of cardiovascular disease (3).

However, a small randomized controlled trial (RCT) called the cardioprotective effects of vitamin D into question (4). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2,500 IUs. Some of the weaknesses of the study were a very short duration and small study size.

How does vitamin D affect mortality?

In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: nine percent reduction with vitamin D plus calcium and seven percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

Does obesity affect vitamin D absorption?

A recently published analysis of data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, found that those with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (2). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs showed none of these benefits.

Can vitamin D help you lose weight?

There is good news, but not great news, on the weight front. It appears that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml, compared to those below this level, in the Study of Osteoporotic Fractures (6).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, vitamin D did not show statistical significance with weight loss.

USPSTF recommendations and fracture risk

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (7). The supplement combination does not seem to reduce fractures, but does increase the risk of kidney stones. There is also not enough data to recommend for or against vitamin D with or without calcium for cancer prevention.

When should you supplement?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it might play an integral role with many disorders. But it is also important not to raise the levels too high. The range that I tell my patients is between 32 and 50 ng/ml, depending on their health circumstances.


(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) JAMA Netw Open. 2023 Published online Jan 2023. (3) Circulation. 2008 Jan 29;117(4):503-511. (4) PLoS One. 2012;7(5):e36617. (5) J Women’s Health (Larchmt). 2012 Jun 25. (6) J Clin Endocrinol Metabol. May 17, 2012 online. (7) JAMA. 2018;319(15):1592-1599.

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.

METRO photo
Exercise is only one part of the weight loss equation

By David Dunaief, M.D.

Dr. David Dunaief

Exercise has benefits for a wide range of medical conditions, from insomnia, fatigue, depression and cognitive decline to chronic kidney disease, diabetes, cardiovascular disease and osteoporosis. But will it help you lose weight? 

While exercise equipment and gym membership ads emphasize this in January, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. 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.

Does exercise help with 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. This is a moderately intense pace.

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

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Does exercise help with weight maintenance?

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

Does exercise help with disease?

As a simple example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects approximately 15 percent of U.S. adults, 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, 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.

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

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


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

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

Photo by David Ackerman

By Leah S. Dunaief

Leah Dunaief

Maybe it sounds like I’m tooting our horn too much, but I have to say how proud I am of the columnists who write for our papers and website. They are clearly bright and offer the reader information and knowledge that aren’t usually found even in a big metro daily or a glossy magazine. They are, collectively and individually, one of the main reasons our hometown newspapers have managed to survive while so many of our colleagues, 25% of them in the nation, have had to shut their doors.

Readers want to learn from our regular columnists, who, by the way, are local residents. That’s not surprising, though, because the population we serve is exceptional, accomplished in their own right, and can be expected to harbor such talent. Let me explain.

The columnists are found in the second section of the newspaper, called Arts & Lifestyles. In the interest of full disclosure and without false modesty, I point out and salute my youngest son, Dr. David Dunaief. He is a physician totally committed to helping his patients, and the high regard is returned by them in equal measure, as testimonials about him confirm. In addition, he writes every week about current medical problems and brings readers up to date with the latest research and thinking regarding common ailments. I know him to be a voracious reader of medical journals and he footnotes his sources of expertise at the end of every “Medical Compass” column. 

Dr. Matthew Kearns is a longtime popular veterinarian who writes “Ask the Vet,” keeping our beloved pets healthy. Michael E. Russell is a successful, retired financial professional who cannot cut the cord with Wall Street, and  shares his thoughts on the economy and suggesting current buys on the stock market. He will also throw in something irreverent, or even askance, to keep you tuned in. 

Also writing knowledgeably on the contemporary scene about finance and the economy is Michael Christodoulou, who is also an active financial advisor. Ever try to read your auto insurance policies? If I had trouble falling asleep, they would knock me out by the second paragraph. Enter A. Craig Purcell, a partner in a long-established local law firm, who is attempting to explain auto insurance coverage, a merciful endeavor, with his column. His words do not put me to sleep. Shannon Malone will alternate the writing for us. Michael Ardolino, a well-known realtor, somehow manages to make both ends of a real estate transaction, for buyers and sellers, sound promising at this time. 

Our lead movie and book reviewer is the highly talented Jeffrey Sanzel. In addition to being a terrific actor, he is a gifted writer and almost always feels the same way about what he is reviewing as I do. No wonder I think he is brilliant.  Father Frank has been writing for the papers for many years and always with great integrity and compassion. 

John Turner, famous naturalist and noted author and lecturer, keeps us apprised of challenges to nature. This is a niche for all residents near the shorelines of Long Island. He also writes “Living Lightly,” about being a responsible earth dweller. Bob Lipinski is the wine connoisseur who travels the world and keeps us aware of best wines and cheeses.

Lisa Scott and Nancy Marr of the Suffolk County League of Women Voters, keep us informed about upcoming elections, new laws and important propositions. Elder law attorney Nancy Burner tells us about Medicare, estate planning, wills gifting, trustees, trusts and other critical issues as we age.

The last columnist I will mention is Daniel Dunaief, who, like bookends for my salute, is also my son. Among several other articles, he writes “The Power of Three,” explaining some of the research that is performed at Stony Brook University, Brookhaven National Labs and Cold Spring Harbor Laboratory. He makes a deep dive into the science in such a way that layman readers can understand what is happening in the labs. He has been paid the ultimate compliment by the scientists for a journalist: they pick up the phone and willingly talk to him, unafraid that he will get the story wrong or misquote them. In fact, he has been told a rewarding number of times by the researchers that his questions for the articles have helped them further direct their work.

When my sons began writing for TBR News Media, a few readers accused me of nepotism. I haven’t heard that charge now in years.

P.S. Of course, we can’t forget Beverly C. Tyler and Kenneth Brady, stellar historians both.

A poor diet can increase your risk for high blood pressure. METRO photo
Medication timing has a significant effect on cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

We are at the point in the year when many of us are taking stock of how we’ve fared over our last trip around the sun. 

If you are one of the 47 percent of U.S. adults over the age of 18 with hypertension, also known as high blood pressure, you don’t want to be one of the 92 million whose hypertension is uncontrolled (1). When it’s not controlled, you increase your probability of complications, such as cardiovascular events and mortality.

What contributes to our risk of hypertension complications?

Being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol are some of the factors that increase our risk (2). The good news is that you can take active steps to improve your risk profile (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits.

Which risk factors have the greatest impact on developing hypertension?

A poor diet can increase your risk for high blood pressure. METRO photo

In an observational study involving 2,763 participants, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (4). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²), which put participants at 1.87 times increased risk. This, surprisingly, trumped cigarette smoking, which increased risk by 1.83 times. 

What effect does your gender, age or race have?

While the data show that more men than women have hypertension, 50 percent vs. 44 percent, and the prevalence of high blood pressure varies by race, the consequences of hypertension are felt across the spectrum of age, gender and race (5).

One of the most feared complications of hypertension is cardiovascular disease. In a study, isolated systolic (top number) hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (6). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. 

High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, it was very large and had a 31-year duration.

Are nighttime blood pressure readings better risk predictors?

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (6).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration.

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

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (7). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

A previous study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Do blueberries help control blood pressure?

Diet plays a role in controlling high blood pressure. In a study, 22 grams of blueberry powder consumed daily, equivalent to one cup of fresh blueberries, reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (9).

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase nitric oxide, which helps blood vessels relax, reducing blood pressure. While the study used powder, it’s possible that an equivalent amount of real fruit would lead to greater reduction.

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


(1) millionhearts.hhs.gov. (2) uptodate.com. (3) Diabetes Care 2011;34 Suppl 2:S308-312. (4) BMC Fam Pract 2015;16(26). (5) cdc.gov. (6) J Am Coll Cardiol 2015;65(4):327-335. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377.

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