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Dr. David Dunaief

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Lignans found in plants can reduce risk. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

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

MYTH: Fruit should be limited or avoided.

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

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

In yet another study, researchers looked at the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

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

MYTH: All carbohydrates raise your sugars.

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

In the Nurses’ Health Study (NHS) and NHS II, two very large prospective observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

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

MYTH: Soy should be avoided when you have diabetes.

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

This was a small randomized control trial over a four-year period with 41 participants. The control group’s diet consisted of 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

MYTH: Bariatric surgery is an alternative to lifestyle changes.

Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery involving 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintaining long-term benefits.

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

References: 

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Obes Surg. 2014;24:437-455.

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

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NSAIDS con contribute to kidney damage

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that the CDC estimates as many as 15 percent of U.S. adults have chronic kidney disease (CKD) and that roughly 90 percent of them don’t know they have it (1). This includes about 50 percent of people with a high risk of kidney failure in the next five years.

How is this possible? CKD is tricky because it tends to be asymptomatic, initially. Only in the advanced stages do symptoms become distinct, although there can be vague symptoms in moderate stages such as fatigue, malaise and loss of appetite. Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease. But those are only the ones at highest risk.

Why does CKD matter?

Your kidneys function as efficient little blood filters. They remove wastes, toxins and excess fluid from the body. In addition, they play roles in controlling blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in the blood. When they’re not operating at full capacity, the consequences can be heart disease, stroke, anemia, infection and depression — among others. According to the U.S. Preventive Services Task Force and the American College of Physicians, those who are at highest risk should be screened including patients with diabetes or hypertension (2)(3).

Slowing CKD progression

Fortunately, there are several options available, ranging from preventing CKD with specific exercise to slowing the progression with lifestyle changes and medications.

Exercise helps – even walking

The results of a study show that walking reduces the risk of death and the need for dialysis by 33 percent and 21 percent respectively (4). Even more intriguing, those who walked more often saw greater results. So, the participants who walked one-to-two times a week had a significant 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a more impressive 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. There were 6,363 participants with an average age of 70, and they were followed for an average of 1.3 years.

How much protein to consume?

When it comes to CKD, more protein is not necessarily better, and it may even be harmful. In a meta-analysis of 17 Cochrane database studies of non-diabetic CKD patients who were not on dialysis, results showed that the risk of progression to end-stage kidney disease, including the need for dialysis or a kidney transplant, was reduced 36 percent in those who consumed a very low-protein diet, rather than a low-protein or normal protein diet (5).

Reducing sodium consumption

Good news! In a study, results showed that a modest sodium reduction in our diet may be sufficient to help prevent proteinuria (protein in the urine) (6). Here, less than 2000 mg was shown to be beneficial, something all of us can achieve.

Medications have a place

We routinely give certain medications, ACE inhibitors or ARBs, to patients who have diabetes to protect their kidneys. What about patients who do not have diabetes? ACEs and ARBs are two classes of anti-hypertensives — high blood pressure medications — that work on the kidney systems responsible for blood pressure and water balance (7). Results of a study show that these medications reduced the risk of death significantly in patients with moderate CKD. Most of the patients were considered hypertensive.

However, there was a high discontinuation rate among those taking the medication. If you include the discontinuations and regard them as failures, then all who participated showed a 19 percent reduction in risk of death, which was significant. However, if you exclude discontinuations, the results are much more robust with a 63 percent reduction. To get a more realistic picture, this result, including both participants and dropouts, is probably close to what will occur in clinical practice unless the physician is a really good motivator or has very highly motivated patients.

Should you be taking NSAIDs?

Non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen, have been associated with CKD progression and with kidney injury in those without CKD (1). For those on ACE inhibitors or ARBs, NSAIDs can also interfere with their effectiveness. Talk to your doctor about your prescription NSAIDs and any other over-the-counter medications you are taking.

Takeaways

You don’t necessarily have to rely on drug therapies to protect your kidneys, and there is no down-side to lifestyle modifications. Lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options, with or without medication. Discuss with your physician whether you need regular screening. High-risk patients with hypertension and diabetes should definitely be screened; however, those with vague symptoms of lethargy, aches and pains might benefit from screening, as well.

References: (1) cdc.gov/kidneydisease (2) uspreventiveservicestaskforce.org (3) aafp.org. (4) Clin J Am Soc Neph-rol. 2014;9(7):1183-9. (5) Cochrane Database Syst Rev. 2020;(10):CD001892. (6) Curr Opin Nephrol Hypertens. 2014;23(6):533-540. (7) J Am Coll Cardiol. 2014;63(7):650-658.

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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A daily quarter-teaspoon increase in sodium can affect kidney function

By David Dunaief, M.D

Dr. David Dunaief

Approximately 37 million U.S. adults have chronic kidney disease (CKD), with as many as 9 in 10 not aware they have it, according to the CDC (1).

Early-stage CKD is associated with a 40 percent increased risk of developing cardiovascular events, such as heart attacks (2). It also significantly increases the risk of peripheral artery disease (PAD). Those with decreased kidney function have a 24 percent prevalence of PAD, compared to 3.7 percent in those with normal kidney function (3). Ultimately, it can progress to end-stage renal (kidney) disease, requiring dialysis and potentially a kidney transplant, so it’s important to identify and treat it.

However, one of the problems with early-stage CKD is that it tends to be asymptomatic. However, there are simple tests, such as a basic metabolic panel and a urinalysis, that will indicate whether you may have mild chronic kidney disease. These indices for kidney function include an estimated glomerular filtration rate (eGFR), creatinine level and protein in the urine. eGFR is a calculation, and while the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 is considered to have mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the severity of chronic kidney disease increases.

What can be done to stem early-stage CKD, before complications occur? There are several studies that have looked at medications and lifestyle modifications and their impacts on its prevention, treatment and reversal.

Does Allopurinol help?

Allopurinol is usually thought of as a medication to prevent gout. 

However, in a randomized controlled trial with 113 patients, results show that allopurinol may help to slow the progression of CKD, defined in this study as an eGFR less than 60 (4). The group using 100 mg of allopurinol showed significant improvement in eGFR levels (compared to the control group) over a two-year period. The researchers concluded that allopurinol slowed CKD progression. Allopurinol also decreased cardiovascular risk by 71 percent.

A 2018 study published in the Journal of the American Medical Association, concluded that allopurinol at a dose of 300 mg or higher reduced the risk of developing stage 3 kidney disease, but less than 300 mg did not (5). However, there is a much smaller 2020 study that shows allopurinol does not help to slow the progression of CKD stage 3 patients (6). This study was very small, but it does raise a question about whether allopurinol truly works.

Diet’s impact

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (7).

What is the significance of metabolic acidosis? It means that body fluids become acidic, and it is associated with chronic kidney disease. The authors concluded that both sodium bicarbonate and a diet including fruits and vegetables were renoprotective, helping to protect the kidneys from further damage in patients with CKD. Alkali diets are primarily plant-based, although not necessarily vegetarian or vegan. Animal products tend to cause an acidic environment.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (8). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower levels of eGFR.

The most interesting part with sodium was that the difference between higher mean consumption and the lower mean consumption was not that large, 2.4 grams compared to 1.7 grams. In other words, a difference of approximately a quarter-teaspoon of sodium was responsible for the decrease in kidney function.

In my practice, when CKD patients follow a vegetable-rich, nutrient-dense diet, there are substantial improvements in kidney functioning. For instance, for one patient, his baseline eGFR was 54. After one month of lifestyle modifications, his eGFR improved by 9 points to 63, which is a return to “normal” functioning of the kidney. Note that this is an anecdotal story and not a study.

Therefore, it is important to have your kidney function checked with mainstream tests. If the levels are low, you should address the issue through medications and lifestyle modifications to manage and reverse early-stage CKD. If you have common risk factors, such as diabetes, smoking, obesity or high blood pressure, or if you are over 60 years old, talk to your doctor about testing. 

Don’t wait until symptoms and complications occur. In my experience, it is much easier to treat and reverse a disease in its earlier stages, and CKD is no exception.

References: 

(1) CDC.gov. (2) N Engl J Med. 2004;351:1296-1305. (3) Circulation. 2004;109:320–323. (4) Clin J Am Soc Nephrol. 2010 Aug;5:1388-1393. (5) JAMA Intern Med. 2018;178(11):1526-1533. (6) N Engl J Med 2020; 382:2504-2513. (7) Clin J Am Soc Nephrol. 2013;8:371-381. (8) Clin J Am Soc Nephrol. 2010; 5:836-843. 

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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Most Americans underconsume potassium   

By David Dunaief, M.D.

Dr. David Dunaief

Most of us know we need to lower our sodium intake. Still, more than 90 percent of us consume far too much sodium (1). Even if we don’t have hypertension, the impact of sodium on our health can be dramatic.

Sodium is insidious; it’s in foods that don’t even taste salty. Bread products are among the primary offenders. Other foods with substantial amounts of sodium include cold cuts and cured meats, cheeses, pizza, poultry, soups, pastas, sauces and, of course, snack foods. Processed foods and those prepared by restaurants are where most of our consumption occurs (2).

On the flip side, only about two percent of people get enough potassium from their diets (3).

Why is it important to reduce sodium and increase potassium? A high sodium-to-potassium ratio increases the risk of cardiovascular disease by 46 percent, according to the study, which looked at more than 12,000 Americans over almost 15 years (4). In addition, both may have significant impacts on blood pressure and cardiovascular disease.

To improve our overall health, we need to shift the sodium-to-potassium balance so that we consume more potassium and less sodium. And if you struggle with high blood pressure, this approach could help you win the battle. Let’s look at the evidence.

Why do we always harp on sodium?

Two studies illustrate the benefits of reducing sodium in high blood pressure and normotensive (normal blood pressure) patients, ultimately preventing cardiovascular disease, including heart disease and stroke.

The first used the prestigious Cochrane review to demonstrate that blood pressure is reduced by a significant mean of −4.18 mm Hg systolic (top number) and −2.06 mm Hg diastolic (bottom number) involving both normotensive and hypertensive participants (5). When looking solely at hypertensive patients, the reduction was even greater, with a systolic blood pressure reduction of −5.39 mm Hg and a diastolic blood pressure reduction of −2.82 mm Hg.

This was a meta-analysis (a group of studies) that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. Salt reduction from 9 to 12 grams per day to 5 to 6 grams per day, determined using 24-hour urine tests, had a dramatic effect. The researchers believe there is a direct linear effect with salt reduction. In other words, the more we reduce the salt intake, the greater the effect of reducing blood pressure. 

The authors recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

In the second study, a meta-analysis of 42 clinical trials, there was a similarly significant reduction in both systolic and diastolic blood pressures (6). This study included both adults and children. Both demographics saw a reduction in blood pressure, though the effect was greater in adults. Interestingly, an increase in sodium caused a 24 percent increased risk of stroke incidence but, more importantly, a 63 percent increased risk of stroke mortality. The risk of mortality from heart disease was increased alongside an increase in sodium, as well, by 32 percent.

In an epidemiology modeling study, the researchers projected that either a gradual or instantaneous reduction in sodium would save lives (7). For instance, a modest 40 percent reduction over 10 years in sodium consumed could prevent 280,000 premature deaths. These are only projections, but in combination with the above studies, they may be telling.

Why is potassium important?

When we think of blood pressure, not enough attention is given to potassium. The typical American diet doesn’t contain enough of this mineral.

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (8). When foods containing 3.5 to 4.7 grams of potassium were consumed, there was an impressive −7.16 mm Hg reduction in systolic blood pressure with high blood pressure patients. Anything more than this amount of potassium did not have any additional benefit. Increased potassium intake also reduced the risk of stroke by 24 percent. This effect was important.

The reduction in blood pressure was greater with increased potassium consumption than with sodium restriction, although this was not a head-to-head comparison. The good news is that potassium is easily attainable in the diet. Foods that are potassium-rich include bananas, almonds, raisins, sweet potato and green leafy vegetables such as Swiss chard.

The bottom line: decrease your sodium intake by almost half and increase potassium intake from foods. Lowering sodium intake may have far-reaching benefits, and it is certainly achievable. First, consume less and give yourself a brief period to adapt — it takes about six weeks to retrain your taste buds, once you cut your sodium. You can also improve your odds by increasing your dietary potassium intake, which also has a substantial beneficial effect, striking a better sodium-to-potassium balance.

References: 

(1) Am J Clin Nutr. 2012 Sep;96(3):647-657. (2) www.cdc.gov. (3) Am J Clin Nutr. 2012 Sep;96(3):647-657. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) BMJ. 2013 Apr 3;346:f1325. (6) BMJ. 2013 Apr 3;346:f1326. (7) Hypertension. 2013; 61: 564-570. (8) BMJ. 2013; 346:f1378.

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 David Dunaief, MD

Dr. David Dunaief

If you are one of the 32.5 million in the U.S. who suffers from osteoarthritis, you know it can make it painful to perform daily tasks. Osteoarthritis (OA) most often affects the knees, hips and hands and can affect sleep quality and mood, in addition to mobility.

Common first-line medications for arthritis pain are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, while medications treat the immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression, and they do have side effects, especially with long-term use.

Here, we’ll focus on approaches you can use to ease pain without reaching for the medicine cabinet. Some may slow worsening — or even reverse symptoms — of your osteoarthritis.

Does dairy help or hurt?

With dairy, specifically milk, there is conflicting information. Some studies show benefits, while others show that it may contribute to the inflammation that makes osteoarthritis pain feel worse.

In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (1). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

The result curve was interesting, however. For those who drank from fewer than three glasses a week up to 10 glasses a week, the progression of joint space narrowing was slowed. However, for those who drank more than 10 glasses per week, there was less beneficial effect. There was no benefit seen in men or with the consumption of higher fat products, such as cheese or yogurt.

However, the study was observational and had significant flaws. First, the 2100 patients were only asked about their milk intake at the study’s start. Second, patients were asked to recall their weekly milk consumption for the previous 12 months before the study began — a challenging task.

On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (2).

Getting more specific, a published analysis of the Framingham Offspring Study found that those who consumed yogurt had statistically significant lower levels of interleukin-6 (IL-6), a marker for inflammation, than those who didn’t eat yogurt, but that this was not true with milk or cheese consumption (3).

We are left with more questions than answers. Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I may not dissuade osteoarthritis patients from yogurt.

Does vitamin D help?

Over the last decade, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief, nor any disease-modifying effects (4). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

The role of weight

Weight management is a crucial component of any OA pain management strategy. In a study involving 112 obese patients, those who lost weight reported a reduction of knee symptoms. Even more exciting, there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5).

On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet for the win!

Diet and exercise trumped the effects of diet or exercise alone in a well-designed study (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a randomized controlled single-blinded study with a duration of 18 months.

Researchers used biomarker IL6 to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times a week.

Therefore, concentrate on lifestyle modifications to reduce pain and potentially disease-modifying effects. The best effects shown are with weight loss and with a vegetable-rich diet. In terms of low-fat or nonfat milk, the results are controversial at best. For yogurt, the results suggest it may be beneficial for osteoarthritis, but stay on the low end of consumption, since dairy can increase inflammation.

References: 

(1) Arthritis Care Res online. 2014 April 6. (2) J Rheumatol. 2017 Jul;44(7):1066-1070. (3) Nutrients. 2021 Feb 4;13(2):506. (4) JAMA. 2013;309:155-162. (5) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (6) JAMA. 2013;310:1263-1273.

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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Medications and lifestyle changes can reduce your risk

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 still underpins one in four deaths in the U.S., making it the leading cause of death (1).

Heart disease is on the decline due to a number of factors, including better awareness in lay and medical communities, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. Heart disease is something that is eminently preventable.

Reduce 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 heart disease risk (3). The underlying culprit is atherosclerosis, fatty streaks in the arteries.

Another potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (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.

Medication’s role in reducing 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.

In terms of lipids, statins have played a key role in primary prevention. Statins are effective at not only lowering lipid levels, including total cholesterol and LDL — the “bad” cholesterol — but also 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, 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.

Do lifestyle changes really help?

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.

Monitoring 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 modification: 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 patient needs to use medications to treat risk factors for heart disease, it should be for the short term. For some patients, it may be appropriate to use medication and lifestyle changes together; for 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.

References: 

(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. 

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Inflammatory responses are at the heart of allergy symptoms        

By David Dunaief, M.D.

Dr. David Dunaief

After last week’s extended blast of winter, we’re all looking forward to warmer weather. This past weekend, we adjusted our clocks for Daylight Saving Time, the unofficial end of winter. We’re just a few weeks out from tree buds and daffodil sprouts. What joy!

However, 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 miserable.

Just over 19 million U.S. adults were diagnosed with seasonal allergies in 2018, and an additional 5.2 million 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 more than likely you have allergies.

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

Treating allergies with medications

The best way to treat allergy attacks is to prevent them, but this 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 do have side effects.

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.

Possible 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) in treating this disorder (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 a 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.

Can you treat 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.

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, though there are no formal studies. There does seem to be promise with some herbs, especially 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.

References: 

(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. 

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Avocados are a great source of micronutrients. METRO photo
Improving calorie quality makes a difference

By David Dunaief, M.D.

Dr. David Dunaief

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. This can make weight management or weight loss very difficult to achieve.

Unfortunately, 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 encourages higher calorie purchases (1, 2).

Does this mean we are doomed to acquiesce to food temptation? Actually, no: It is not solely about willpower. Changing diet composition is more important.

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 solely 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. But don’t take my word for it. Let’s look at the evidence.

Refined carbohydrates

Many of us know that refined carbohydrates are not beneficial. Worse, however, a randomized control trial (RCT) showed refined carbohydrates 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. Granted, this was a very small study, but it was well designed. High-glycemic foods include carbohydrates, such as white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates. Calorie composition matters.

Comparing macronutrients

We tend to focus on macronutrients when looking at diets. These include protein, carbohydrates and fats, 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 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.

Micronutrient deficiency

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 lacking in micronutrients (6). These 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 won’t solve the problem; supplements don’t compensate for missing micronutrients. Quite the contrary, 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.

Cortisol levels

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

Why is this important? Cortisol is a glucocorticoid, which means it raises the level of glucose and is involved in mediating visceral or belly fat. This type of fat has been thought to 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 calories have an impact, the nutrient density of the food may be more important. Thus, those foods high in a variety of micronutrients may also play a significant role in reducing cravings, ultimately helping to manage weight.

References: 

(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.

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Some medication side-effects include increased fall risk

By David Dunaief, M.D.

Dr. David Dunaief

This has been a particularly challenging winter here in the Northeast. Instead of snow, we’ve had a fair amount of ice and variable temperatures that caused snowy surfaces to ice over.

Many older adults are concerned about falling, thus they stayed inside and sedentary. While this addressed the immediate challenge of icy sidewalks, it may have increased their risk of falling in the future.

What drives this concern about falls? 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).

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).

Setting yourself up for success

Of the utmost importance is exercise. But what do we mean by “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.

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

Does medication increase risk?

There are a number of medications that may heighten fall risk. As I mentioned, psychotropic drugs top the list. But what other drugs might have an impact?

High blood pressure medications have been investigated. 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.

Blood pressure medications have significant benefits in reducing the risks of cardiovascular disease and events. Thus, we need to weigh 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 risk of falling (8).

What types of exercise help?

Any consistent exercise program that improves balance, flexibility, and muscle tone and includes core strengthening should help you 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.

Thus, our best line of defense against fall risk is prevention with exercise and reducing slipping opportunities. Should you stop medications? Not necessarily. But for those 65 and older, or for those who 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.

References: 

(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. 

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Studies suggest the microbiome may influence weight loss or gain

By David Dunaief, M.D.

Dr. David Dunaief

Each of us carries trillions of microorganisms in our bodies. These make up each individual’s microbiome. It includes 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 microbes have key roles in our healthy functioning.

While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where the majority of the microbiome resides.

Why do we care? The short answer is it may have a role in diseases — preventing and promoting them. These include obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

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 spur future research. There have been some enlightening preliminary studies already.

What affects the microbiome? Drugs, such as antibiotics, can wipe out the diversity in the microbes, at least in the short term. Also, lifestyle modifications, such as diet, can have an impact. Microbiome diversity also may be significantly different in distinct geographic locations throughout the world.

Microbiome’s role in obesity

Obesity can be incredibly frustrating; most obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

I know this will not come as a surprise, but we are a nation with a weight problem; about 70% of Americans are overweight or obese (2) (3). For the longest time, the paradigm for weight loss had been to cut calories. However, extreme low-caloric diets did not seem to have 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 (4). 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. But they only lost weight when on a good diet; there was no impact if the diet was not low in fat. 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 definitely suggests that the diversity of gut bacteria may be a crucial piece of the weight-loss puzzle.

Possible role for gut bacteria in rheumatoid arthritis development

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 (5). 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.

Counteracting antibiotics’ gut effects

Many experience gastrointestinal upset while taking antibiotics. This is because antibiotics don’t differentiate between good and bad bacteria when they go to work. One way to counteract the 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 (6). 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.

References: 

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) cdc.gov (3) nih.gov (4) Science. 2013;341:1241214. (5) PLoS One. 2012;7:e36095. (6) 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. 

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