Tags Posts tagged with "Dr. David Dunaief"

Dr. David Dunaief

Aerobic exercise is good for the brain. METRO photo
Exercise may improve mild cognitive impairment

By David Dunaief, M.D.

Dr. David Dunaief

As we consider aging, many of us fear loss of our mental capability as much as loss of our physical capabilities. Yet, just as with physical capabilities, age is not the only determinant.

Mild cognitive impairment (MCI) is feared, not only for its own challenges but also because it may lead to dementia, with Alzheimer’s disease and vascular dementia being the more common forms. Prevalence of MCI may be as high as one-in-five in those over age 70 (1). It is thought that those with MCI may have a 10 percent chance of developing Alzheimer’s disease (2).

So, the most compelling questions are: What increases risk and what can we do to minimize the risk of developing cognitive impairment? Many chronic diseases and disorders contribute to MCI risk. These include diabetes, heart disease, Parkinson’s disease and strokes. If we can control these, we may reduce our risk of cognitive decline.

Heart disease creates substantial risk

In an observational study, results demonstrated that those suffering from years of heart disease are at a substantial risk of developing MCI (3). The study involved 1,450 participants who were between the ages of 70 and 89 and were not afflicted by cognitive decline at the beginning of the study. Patients with a history of cardiac disease had an almost two times greater risk of developing nonamnestic MCI, compared to those individuals without cardiac disease. Women with cardiac disease were affected even more, with a three times increased risk of cognitive impairment.

Nonamnestic MCI can affect executive functioning — decision-making abilities, spatial relations, problem-solving capabilities, judgments and language. It is a more subtle form of impairment that may be more frustrating because of its subtlety. It may lead to vascular dementia and may be a result of clots.

Strokes: where is more important than how many

Not surprisingly, stroke may have a role in cognitive impairment. Stroke is also referred to as a type of vascular brain injury. But what is surprising is that in a study, results showed that the location of the stroke was more relevant than the frequency or the multitude of strokes (4). If strokes occurred in the cortical and subcortical gray matter regions of the brain, executive functioning and memory were affected, respectively. Thus, the locations of strokes may be better predictors of subsequent cognitive decline than the number of strokes. Clinically silent strokes that were found incidentally by MRI scans had no direct effect on cognition, according to the authors.

Exercise benefits cognitive functioning

Exercise may play a significant role in preventing cognitive decline and possibly even improving MCI in patients who have the disorder. Interestingly, different types of exercise have different effects on the brain. Aerobic exercise may stimulate one type of neuronal development, while resistance training or weightlifting another.

In an animal study involving rats, researchers compared aerobic exercise to weightlifting (5). Weightlifting was simulated by attaching weights to the tails of rats while they climbed ladders. Both groups showed improvements in memory tests, however, there was an interesting divergence.

With aerobic exercise, the level of the protein BDNF (brain-derived neurotrophic factor) increased significantly. This is important, because BDNF is involved in neurons and the connections among them, called synapses, related mostly to the hippocampus, or memory center. The rats that “lifted weights” had an increase in another protein, IGF (insulin growth factor), that promotes the development of neurons in a different area of the brain. The authors stressed the most important thing is to exercise, regardless of the type.

In another study that complements the previous study, women were found to have improved spatial memory when they exercised — either aerobic or weightlifting (6). Interestingly, verbal memory was improved more by aerobic exercise than by weightlifting. Spatial memory is the ability to recall where items were arranged, and verbal memory is the ability to recall words. The authors suggest that aerobic exercise and weightlifting affect different parts of the brain.

This was a randomized controlled trial that was six months in duration and involved women, ages 70 to 80, who had MCI at the trial’s start. There were three groups in the study: aerobic, weightlifting and stretching and toning. Those who did stretches or toning alone experienced deterioration in memory skills over the same period.

A Centers for Disease Control and Prevention report claims the majority of the adult population is woefully deficient in exercise: Only about 1 in 5 Americans exercise regularly, both using weights and doing aerobic exercise (7).

Diet makes a difference

Several studies show that the Mediterranean diet helps prevent MCI and possibly prevents conversion from MCI to Alzheimer’s (8, 9). In addition, a study showed that high levels of carbohydrates and sugars, when compared to lower levels, increased the risk of cognitive decline by more than three times (5). The authors surmise that carbohydrates have a negative impact on insulin and glucose utilization in the brain.

Cognitive decline should be taken very seriously, and everything that can be done to prevent it should be utilized. Exercise has potentially positive effects on neuron growth and development, and controlling carbohydrate and sugar intake may reduce risk. Of course, if you have cardiovascular disease, making lifestyle changes to reverse or minimize its impact will reap both physical and cognitive rewards. Let’s not squander the opportunity to reduce the risk of MCI, a potentially life-altering disorder.

References:

(1) Ann Intern Med. 2008;148:427-434. (2) uptodate.com. (3) JAMA Neurol. 2013;70:374-382. (4) JAMA Neurol. 2013;70:488-495. (5) J Alzheimers Dis. 2012;32:329-339. (6) J Aging Res. 2013;2013:861893. (7) Morb Mortal Wkly Rep. 2013;62:326-330. (8) Neurology 2013;80:1684-1692. (9) Arch Neurol. 2009 Feb.;66:216-225.

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. 

Micronutrients are vitamins and minerals needed by the body in very small amounts. METRO photo
Micronutrient focus may reduce cravings

By David Dunaief, M.D.

Dr. David Dunaief

If we needed any more proof, this past year has been a good reminder that 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 temptation? Actually, no: It is not solely about willpower. Changing diet composition is more important.

How can we alter the dynamic? 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, 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.

Examining refined carbohydrates

Many of us know that refined carbohydrates are not beneficial. Worse, however, a randomized control trial 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.

Adding micronutrients

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.

Lowering 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. 

Yoga can improve balance and strength, which are risk factors for falls. METRO photo
Fear of falling can lead to greater risk

By David Dunaief, M.D.

Dr. David Dunaief

Earlier in life, falls usually do not result in significant consequences. However, once we reach middle age, falls become more substantial. Even without icy steps and walkways, falls can be a serious concern for older patients, where 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).

Contributors to fall risk

Many factors contribute to fall risk. A personal history of falling in the recent past is the most prevalent. But there are many other significant factors, such as age and medication use. Some medications, like antihypertensive medications used to treat high blood pressure and psychotropic medications 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 fall prevention tips

Of the utmost importance is exercise. But what do we mean by “exercise”? Exercises involving balance, strength, movement, flexibility and endurance all play significant roles in fall prevention (4).

Many of us in the Northeast are also low in vitamin D, which may strengthen muscle and bone. This is an easy fix with supplementation. Footwear also needs to be addressed. Nonslip shoes are crucial indoors, and outside in winter, footwear that prevents sliding on ice is a must. Inexpensive changes in the home, like securing area rugs, can also make a big difference.

Medication side-effects

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 propensity-matched sample study (a notch below a randomized control trial in terms of quality) 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.

While blood pressure medications may contribute to fall risk, they 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 considering stopping a medication. When it comes to treating high blood pressure, lifestyle modifications may also play a significant role in treating this disease (6).

How exercise helps

All exercise has value. A meta-analysis of a group of 17 trials showed that exercise significantly reduced the risk of a fall (7). If the categories are broken down, exercise led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in those 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. Thus, 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?

Tai chi, yoga and aquatic exercise have 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 number of falls from a mean of 2.00 to a fraction of this level — a mean of 0.29. There was also 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 in a randomized control trial of 60 male and female participants (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. Does this mean stopping 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 considering changing your blood pressure medications, review the 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. 

Stock photo

Building heart-healthy habits improves the likelihood we’ll be around for those we love

By David Dunaief, M.D.

Dr. David Dunaief

This February, we celebrate both Valentine’s Day, an opportunity to celebrate those we love, as well as American Heart Month, a chance for us to build awareness of heart-healthy habits.

The good news is that 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.

Reducing our risks

Risk factors for heart disease include obesity, high cholesterol, high blood pressure, smoking and diabetes. Unfortunately, both obesity and diabetes are on the rise. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (1). However, high blood pressure, high cholesterol and smoking have declined (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.

When medication helps reduce risk

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. The compliance with blood pressure medications has increased over the last 10 years from 33 to 50 percent, according to the American Society of Hypertension.

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 (5).

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 when they come to see me is to reduce and ultimately discontinue their statins by following a lifestyle modification plan involving diet and exercise. Lifestyle modification is a powerful ally.

Making lifestyle changes

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 (6). 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. There was a decrease in SCD that was dose-dependent, meaning the more factors incorporated, the greater the risk reduction. There was as much as a 92 percent decrease in SCD risk when all four parameters were followed (7). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

Monitoring your risk of heart disease

To determine your progress, we use cardiac biomarkers, 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. The results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life. The best part is the results occurred over a very short period to time — three months from the start of the trial (8). Many patients I have seen have had 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 patients take an active role.

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

References:

(1) Diabetes Care. 2010 Feb; 33(2):442-449. (2) JAMA. 2005;293(15):1868. (3) Lancet. 2004;364(9438):93. (4) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (5) JAMA. 2011;305(24):2556-2564. (6) J Nutr. March 1, 2005;135(3):556-561. (7) JAMA. 2011 Jul 6;306(1):62-69. (8) 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. 

What your microbiome really needs is fiber. Stock photo
Studies show significant short-term changes to the microbiome when eating fruits, vegetables and plant fiber

By David Dunaief, M.D.

Dr. David Dunaief

Considering our recent focus on cleansing germs from every surface, it’s a leap to acknowledge that we harbor a multitude of microorganisms, or microbes, in our bodies. We have so many, over one trillion microorganisms, that they outnumber our cells by a 10-to-1 ratio, even in healthy individuals.

These make up what we call the microbiome. It includes bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, spanning from parasitic to commensalistic (one benefits and the other is not affected) to mutualistic (both benefit). 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 about the gut microbiome? 

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. Like the Human Genome Project, which mapped our genes, there is a Human Microbiome Project, launched by the National Institutes of Health in 2007, to map out the composition and diversity of these gut organisms. We are still in the early stages of understanding this vast universe of microbes, yet there have been some preliminary studies.

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. Let’s look at the evidence.

Using twins to study obesity

Obesity can be one of the most frustrating disorders; 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 that if you ate fewer calories, you would lose weight. 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. Let’s look at the data on obesity.

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.

Do gut bacteria influence 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.

Although nobody can say what the ideal gut bacteria should consist of, and the research is still evolving when it comes to the microbiome, there are potential ways of influencing this milieu, especially in our gut. 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, inflammatory bowel syndrome 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. 

Blood pressure numbers of less than 120/80 mm Hg are considered within the normal range.
Nighttime blood pressure readings may be more accurate predictors

By David Dunaief, M.D.

Dr. David Dunaief

What could we possibly learn about blood pressure that we have not heard already? Studies teach us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. 

Two arms please

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms, because there may be significant benefit from this.

Researchers analyzed the Framingham Heart Study and Offspring Study and found that when blood pressure was taken in both arms and there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, they could identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack (1).

So, the next time you go to the doctor’s office, ask them to take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Night beats daytime

When do you take your blood pressure? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (2). 

This was a meta-analysis of nine observational studies involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account. However, every 10 mm Hg increase at night had a significant predictive value.

With patients, if blood pressure is high in my office, I suggest that they take their blood pressure at home, both in the morning and at night, and send me weekly readings. At least one of the readings should be taken before antihypertensive medications are taken, since these will alter the numbers.

Pass on the salt

There has always been a debate about whether salt plays a role in high blood pressure and heart disease. A compelling British study, called the Health Survey from England, implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (3). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

One potential study weakness was that physical activity was not taken into account. However, this study’s strength was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods we least suspect, such as breads, pastas and cheeses.

Check your eyes

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (4). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics, and angiotensin receptor blockers.

However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Manage your fall risk

One study shows that blood pressure medications significantly increase fall risk in the elderly (5). Overall, nine percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

So, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.

References:

(1) Am J Med. 2014 Mar;127(3):209-215. (2) J Am Soc Hypertens 2014;8:e59. (3) BMJ Open 2014;4:e004549. (4) Ophthalmology online April 30, 2014. (5) JAMA Intern Med. 2014;174(4):588-595.

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. 

Sleep clears toxins from the brain. METRO photo
Exercise and sleep are crucial to clearing the clutter

By David Dunaief, M.D.

Dr. David Dunaief

Considering the importance of our brain to our functioning, it’s startling how little we know about it. 

We do know that certain drugs, head injuries and lifestyle choices negatively impact the brain. There are also numerous disorders and diseases that affect the brain, including neurological (dementia, Parkinson’s, stroke), infectious (meningitis), rheumatologic (lupus and rheumatoid arthritis), cancer (primary and secondary tumors), psychiatric mood disorders (depression, anxiety, schizophrenia), diabetes and heart disease.

Although these diseases vary widely, they generally have three signs and symptoms in common: they either cause altered mental status, physical weakness or change in mood — or a combination of these.

Probably our greatest fear regarding the brain is a loss of cognition. Fortunately, there are several studies that show we may be able to prevent cognitive decline by altering modifiable risk factors. They involve rather simple lifestyle changes: sleep, exercise and possibly omega-3s.

Let’s look at the evidence.

Clutter slows us down as we age

The lack of control over our mental capabilities as we age frightens many of us. Those who are in their 20s seem to be much sharper and quicker. But are they really?

In a study, German researchers 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. We may need a reboot just like a computer. This may be possible through sleep, exercise and omega-3s.

Get enough sleep

Why should we dedicate 33 percent of our lives to sleep? There are several good reasons. One involves clearing the mind, and another involves improving our economic outlook.

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 another study, done in Australia, results showed that sleep deprivation may have been responsible for an almost one percent decline in gross domestic product for the country (3). The reason? People are not as productive at work when they don’t get enough sleep. They tend to be more irritable, and concentration may be affected. We may be able to turn on and off sleepiness on short-term basis, depending on the environment, but we can’t do this continually.

According to the Centers for Disease Control and Prevention, four percent of Americans reported having fallen asleep in the past 30 days behind the wheel of a car (4). And “drowsy driving” led to 83,000 crashes in a four-year period ending in 2009, according to The National Highway Traffic Safety Administration.

Prioritize exercise

How can I exercise, when I can’t even get enough sleep? Well there is a study that just may inspire you.

In the study, which involved rats, those that were not allowed to exercise were found to have rewired neurons in the area of their medulla, the part of the brain involved in breathing and other involuntary activities. There was more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (5). In 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.

This is intriguing since we used to think that our brain’s plasticity, or ability to grow and connect neurons, was finite and stopped after adolescence. This study’s implication is that a lack of exercise causes unwanted new connections. Human studies should be done to confirm this impact.

Consume omega-3 fatty acids

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 (6). 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 either have been from fish or 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.

References:

(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) J Comp Neurol. 2014 Feb. 15;522:499-513. (6) 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. 

Start the year out right by substituting green leafy vegetables for breads and other baked goods. METRO photo
Simple modifications can help you achieve your health goals

By David Dunaief, M.D.

Dr. David Dunaief

2020 has been a most unusual year. In some ways, it’s been a case study in new habit formation, as many of us altered our routines to adapt to a COVID-19 world.

As our thoughts turn to a brighter 2021, many of us will make resolutions to develop healthy new habits – and in some cases to undo bad habits we’ve picked up during the past year. If this is you, cheers!

Changing habits can be incredibly difficult. You can make it easier on yourself, though. 

Set a goal that is simple and singular. Don’t overdo it by focusing on multiple resolutions, like eating better, exercising more and sleeping better. Complexity will diminish your chances of success. Instead, pick one to focus on, and make the desired impact part of your goal, for example: improve your health by substituting green leafy vegetables for breads and other baked goods.

Manage your environment. According to a study, people with the most self-control utilize the least amount of willpower, because they take a proactive role in minimizing temptation (1). Start by changing the environment in your kitchen. In our example resolution above, that means eliminating or reducing the breads and baked goods in your home and keeping a refrigerator stocked with leafy greens you like.

If one obstacle is the time available to cook when you’re hungry, consider in advance the ways you can make in-the-moment food preparation simpler. This could be as simple as pre-washing and chopping greens when you arrive home from the store or while watching your favorite TV program, or it could be as detailed as precooking meals.

The latter is my personal favorite, and it’s easily accomplished by cooking more than you need for a single meal. For example, rather than chop and roast just the tray of broccoli we’ll eat tonight, we’ll prepare two trays at a time – one to eat today, and one to have in the fridge. I try to always have at least one prepared healthy meal at the ready for reheating, in case we don’t have the time or energy to cook later.

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

One reason so many have turned to baking during their at-home time is that it provides a fun group activity with a shared outcome. You can produce the same experience by experimenting with new greens-intensive recipes together. Making pots of vegetable stews and chilis, vegan spinach lasagnas with bean noodles, bean-and-green tacos, and cheeseless eggplant/spinach rollatini can be more fun as a group – with the same delicious outcomes. Bonus: if you double the recipes, you can refrigerate or even freeze the leftovers for reheating later.

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

Choose a diet that targets your health needs. U.S. News and World Report released its annual ranking of diets this week (3). Three of the diets highlighted include the DASH (Dietary Approach to Stop Hypertension) diet, the Ornish diet and the Mediterranean diet. These were the top three for heart health. The Mediterranean diet was ranked number one overall – for the fourth consecutive year – and the DASH diet tied for second overall with the Flexitarian diet. The Flexitarian and Mediterranean diets tied for the top spot for diets that help manage diabetes.

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

Of course, if you’ve tried to change your diet in the past, you probably know that not every diet is easy to follow, even after you get beyond the “changing my eating habits” part of the equation. Choosing a diet that works for both you and others in your household can be tricky. And, let’s face it, no one wants to make two meals – or more – to accommodate everyone’s needs.

According to U.S. News and World Report, the easiest to follow are the Mediterranean diet, which took the top spot, the recently redesigned WW (Weight Watchers) diet, which took second place, and the Flexitarian diet, which came in third. If you’re not familiar with a Flexitarian diet, which we noted also tied for the second-best diet overall, its name is a combination of “flexible” and “vegetarian,” and its focus is on increasing your intake of fruits and vegetables and minimizing – but not necessarily eliminating – your intake of animal products. For many, this lack of rigidity can help, whether the goal is to transition to a complete vegetarian lifestyle eventually or to manage different palates around the table.

I encourage you to read more about each of these diets and select one, in consultation with your physician, that will help you meet your personal health goals – from both nutritional and manageability standpoints.

Here’s to a happy, healthy 2021!

References:

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

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. 

Statins may be overprescribed for the primary prevention of cardiovascular disease. Stock photo
Do primary prevention benefits outweigh the risks?

By David Dunaief, M.D.

Dr. David Dunaief

Statins were first approved in the U.S. over 30 years ago. Today, they are one of the most commonly prescribed medications in the United States. Yet, many in the medical community still disagree about who should be taking a statin and for what purpose; some believe that more patients should be on this class of drugs, while others think it is overprescribed. This is one of the most polarizing issues in medicine — probably rightly so.

The biggest debate is over primary prevention with statins. Primary prevention is treating people with high cholesterol and/or inflammation who may be at risk for a cardiovascular event, such as a stroke or heart attack. Currently, recommendations of the American College of Cardiology and the American Heart Association do not align with those of the U.S. Preventive Services Task Force, which is currently reviewing its own recommendations because of data updates.

Most physicians agree that statins have their place in secondary prevention — treating patients who have had a stroke or heart attack already or who have coronary artery disease.

We will examine benefits and risks for the patient population that could take statins for primary prevention. On one side are those who point to statins’ benefits: reduced cancer risk, improved quality of life and lowered glaucoma risk. On the other, we have those who note statins’ side effects: increased diabetes risk, fatigue and cataracts, to name a few. Let’s look at some of the evidence.

Effect on cancer

A study published in The New England Journal of Medicine involved 300,000 Danish participants and investigated 13 cancers. It showed that statin users may have a 15 percent decreased risk of death from cancer (1). As you can imagine, this news was greeted with excitement.

However, there were major limitations with the study. First, researchers did not control for smoking, which we know is a large contributor to cancer. Second, it was unknown which of the statin-using population might have received conventional cancer treatments, such as radiation and chemotherapy. Third, the dose of statins did not correlate to risk reduction. In fact, those who took 1 to 75 percent of prescribed statin levels showed more benefit in terms of cancer mortality risk than those who took more. We need a better-designed trial to determine whether there really is an effect.

Another study, a meta-analysis of 13 observational studies, showed that statins may play a role in reducing the risk of esophageal cancer. This is important, since esophageal cancer, especially adenocarcinoma that develops from Barrett’s esophagus, is on the rise. The results showed a 28 percent risk reduction in this type of cancer. The authors of the study surmise that statins may have a protective effect (2).

Although there is an association, these results need to be confirmed with randomized controlled trials. Aspirin has about the same 30 percent reduction in colorectal cancer, yet is not recommended solely for this use because of side effects.

Eye diseases: mixed results

In two common eye diseases, glaucoma and cataracts, statins have vastly different results. In one study, statins were shown to decrease the risk of glaucoma by five percent over one year and nine percent over two years (3). It is encouraging that the longer the duration of statin use, the greater the positive effect on preventing glaucoma.

Statins also help to slow glaucoma progression in patients suspected of having early-stage disease at about the same rate. This was a retrospective study analyzing statin use with patients at risk for open-angle glaucoma. We need prospective (forward-looking) studies. With cataracts, it is a completely different story. Statins increase the risk of cataracts by over 50 percent, as shown in the Waterloo Eye Study (4). Statins exacerbate the risk of cataracts in an already high-risk group, diabetes patients.

Quality of life and longevity: a mixed bag

In a meta-analysis involving 11 randomized controlled trials, statins did not reduce the risk of all-cause mortality in moderate to high-risk primary prevention participants (5). This study analysis involved over 65,000 participants with high cholesterol and at significant risk for heart disease.

However, in this same study, participants at high risk of coronary heart disease saw a substantial improvement in their quality of life with statins. In other words, the risk of a nonfatal heart attack was reduced by more than half and nonfatal strokes by almost half, avoiding the potentially disabling effects of these events.

Fatigue effect

Some of my patients who are on statins ask if statins can cause fatigue. A randomized controlled trial published in the Archives of Internal Medicine reinforces the idea that statins increase the possibility of fatigue (6).

Women, especially, complained of lower energy levels, both overall and on exertion, when they were blindly assigned to a statin-taking group. The trial had three groups: two that took statins, simvastatin 20 mg and pravastatin 40 mg; and a placebo group. The participants were at least 20 years old and had LDL (bad) cholesterol of 115 to 190 mg/dl, with less than 100 mg/dl considered ideal.

In conclusion, some individuals who are at high risk for cardiovascular disease may need a statin, but with the evidence presented, it is more likely that statins are overprescribed in primary prevention. Evidence of the best results points to lifestyle modification, with or without statins, and all patients with elevated LDL (bad) cholesterol should make changes that include a nutrient-dense diet and a reduction in fat intake, as well as exercise.

References:

(1) N Engl J Med 2012;367:1792-1802. (2) Clin Gastroenterol Hepatol. 2013 Jun; 11(6):620–629. (3) Ophthalmology 2012;119(10):2074-2081. (4) Optom Vis Sci 2012;89:1165-1171. (5) Arch Intern Med 2010;170(12):1024-1031. (6) Arch Intern Med 2012;172(15):1180-1182.

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

METRO photo

By David Dunaief, M.D.

Dear Santa,

Dr. David Dunaief

I know this is a busy time of year for you. I’m sure it’s all you can do to field all the requests you’re receiving through email, Twitter, WhatsApp, and old-fashioned, handwritten letters. Still, I’d like to suggest that you can provide far more value by becoming a model for good health than you can with any wrapped package tucked under a tree.

Think about the example you’re setting for all those people whose faces light up when they imagine you shimmying down their chimneys. With your abnormally high BMI (body mass index), I know you can do better.

We already have an epidemic of overweight kids, leading to an ever-increasing number of type 2 diabetics at younger and younger ages. According to the Centers for Disease Control and Prevention, as of 2018, more than 100 million U.S. adults are living with diabetes or prediabetes. It complicates the issue that approximately two-thirds of the U.S. population is overweight and/or obese. You can help change this.

Obesity has a much higher risk of shortening a person’s life span, not to mention affecting their quality of life. The most dangerous type of obesity is an increase in visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if a waistline, measured from the navel, is greater than or equal to 40 inches for a man, and is greater than or equal to 35 inches for a woman. The chances of diseases such as pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is a chance for you to lead by example (and, maybe by summer, to fit into those skinny jeans you hide in the back of your closet). Think of the advantages to you of being slimmer and trimmer. Your joints wouldn’t ache with the winter cold, and you would have more energy. Plus, studies show that with a plant-based diet, focusing on fruits and vegetables, you can reverse atherosclerosis, clogging of the arteries.

The importance of a good diet not only helps you lose weight, but avoid strokes, heart attacks and peripheral vascular diseases, among other ailments. You don’t have to be vegetarian; you just have to increase your fruits, vegetables and whole-grain foods significantly. With a simple change, like eating a handful of raw nuts a day, you can reduce your risk of heart disease significantly. Santa, future generations need you. Losing weight will also change your center of gravity, so your belly doesn’t pull you forward. This will make it easier for you to keep your balance on those steep, icy rooftops.

Exercise will help, as well. Maybe for the first continent or so, you might want to consider walking or jogging alongside the sleigh. As you exercise, you’ll start to tighten your abs and slowly see fat disappear from your midsection. Your fans everywhere leave you cookies and milk when you deliver presents. It’s a tough cycle to break, but break it you must. You — and your fans — need to see a healthier Santa.

You might let slip that the modern Santa enjoys fruits, especially berries, and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in hummus, which have substantial antioxidant qualities and can help reverse disease. And, of course, skip putting candy in the stockings. No one needs more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a piece, yourself.

As for your loyal fans, you could place fitness videos under the tree. You and your elves could make workout videos for those of us who need them, and we could follow along as you showed us “12 Days of Workouts with Santa and Friends.” Who knows, you might become the next Shaun T!

You could gift athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games. Or wearable devices that track step counts and bike routes. Or stuff gift certificates for dance lessons into people’s stockings. These might influence the recipients to be more active. By doing all this, you might also have the kind of energy that will make it easier for you to steal a base or two during the North Pole Athletic League’s softball season. The elves don’t even bother holding you on base anymore, do they?

As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll find yourself parking the sleigh farther away and skipping from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Your reindeer won’t have to work so hard. You might fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!

Wishing you good health in the coming year,

David.

P.S. If you have a little extra room in your sleigh, I’d love a new baseball glove.

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.