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Dr. David Dunaief

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Walking helps strengthen your joints, bones and muscles. METRO photo
Walking’s benefits extend beyond physical fitness

By David Dunaief, M.D.

Dr. David Dunaief

There is great emphasis on exercise in medicine and in society. We have heard it is good for us ever since we were children in gym class striving for the presidential fitness award.

The average reaction, unfortunately, is an aversion to exercise. As kids, many of us tried to get out of gym class, and as adults, we “want” to exercise, but we “don’t have time.” The result of this is a nation of couch potatoes. I once heard that the couch is the worst deep-fried food. It perpetuates inactivity, especially when watching TV. Even sleeping burns more calories.

I think part of the problem, generally, is that we don’t know what type of exercise is best and how long and frequently to do it. These days, for many who depend on gyms, dance studios and other exercise-related facilities for exercise are struggling to find meaningful substitutes.

Well, guess what? There is an easy way to get tremendous benefit with very little time involved. You don’t need expensive equipment, and you don’t have to join a gym. You can sharpen your wits with your feet.

Jane Brody has written in The New York Times’ Science Times about Esther Tuttle. Esther was 99 years old, sharp as a tack and was independently mobile, with no aids needed. She continued to stay active by walking in the morning for 30 minutes and then walking again in the afternoon. The skeptic might say that this is a nice story, but its value is anecdotal at best.

Well, evidence-based medicine backs up her claim that walking is a rudimentary and simple way to get exercise that shows incredible benefits. One mile of walking a day will help keep the doctor away.

Walking has a powerful effect on preserving brain function and even growing certain areas of the brain (1). Walking between six and nine miles a week, or just one mile a day, reduced the risk of cognitive impairment over 13 years and actually increased the amount of gray matter tissue in the brain over nine years.

Those participants who had an increase in brain tissue volume had a substantially reduced risk of developing cognitive impairment. Interestingly, the parts of the brain that grew included the hippocampus, involved with memory, and the frontal cortex, involved with short-term memory and executive decision making. There were 299 participants who had a mean age of 78 and were dementia free at the start of the trial. Imagine if you started earlier?

In yet another study, moderate exercise reduced the risk of mild cognitive impairment with exercise begun in mid-to-late life (2).

Even better news is that, if you’re pressed for time or if you’re building up your stamina, you can split a mile into two half-mile increments. How long does it take you to walk a half-mile? You’ll be surprised at how much better you will feel — and how much sharper your thinking is.

This is a terrific strategy to get you off the couch or away from your computer, another hazard for many of us working or schooling from home. Set an alarm for specific points throughout the day and use that as a prompt to get up and walk, even if only for 15 minutes. The miles will add up quickly.

In addition to the mental acuity benefits, this may also help with your psychological health, giving you a mental break from endless Zoom calls and your eyes a break from endless screens.

If you ratchet up the exercise to running, a study showed that mood also improves, mollifying anger (3). The act of running actually increases your serotonin levels, a hormone that, when low, can make people agitated or angry. So, exercise may actually help you get your aggressions out.

Walking has other benefits as well. We’ve all heard about the importance of doing weight-bearing exercise to prevent osteoporosis and osteoporotic fractures. The movie “WALL-E” even did a spoof on this, projecting a future where people lived in their movable recliners. The result was a human skeletal structure that had receded over the generations from lack of use. Although it was tongue-in-cheek, it wasn’t too far from the truth; if you don’t use them, bones weaken and break. Walking is a weight-bearing exercise that helps strengthen your joints, bones and muscles.

So, remember, use your feet to keep your mind sharp. Activities like walking will help you keep a positive attitude, preserve your bones and help increase the plasticity of your brain.

References:

(1) Neurology Oct 2010, 75 (16) 1415-1422. (2) Arch Neurol. 2010;67(1):80-86. (3) J Sport Exerc Psychol. 2010 Apr;32(2):253-261.

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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It is important to drink water prior to and during exercise to avoid heart palpitations. METRO photo
Consequences of mild dehydration are subdued mood, decreased concentration, fatigue and headaches

By David Dunaief, M.D.

Dr. David Dunaief

With this summer’s hottest days right around the corner, discussing dehydration is timely. Even air conditioning can be dehydrating.

Complications and symptoms of dehydration can be mild to severe, ranging from constipation, mood changes, headaches and heart palpitations to heat stroke, migraines and heart attacks.

Dehydration is simple to avoid, right? Not necessarily. We may be dehydrated before experiencing symptoms of thirst.

Headaches and migraines

Temperature is a potential trigger for headaches and migraine. As the temperature rises by intervals of 9 degrees, the risk for headache and migraines increases by eight percent (1). This study involved 7,054 participants from one emergency room site. Warmer temperatures can potentially reduce blood volume in the body, causing artery dilation and resulting in higher risk of headaches and migraines.

In another study, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (2). Headache intensity decreased as well. Anecdotally, I had a patient who experienced a potentially dehydration-induced migraine after playing sports in the sweltering heat of Florida. He had the classic aura and was treated with hydration, Tylenol and caffeine, which helped avoid much of the suffering.

Heart palpitations

It is important to drink water prior to and during exercise to avoid heart palpitations. METRO photo

Heart palpitations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise are contributing factors (3). They occur mainly when we don’t hydrate prior to exercise. All we need to do is drink one glass of water prior to exercise and then drink during exercise to avoid palpitations. Though these symptoms are not usually life-threatening, they are anxiety producing for patients.

Potential for heart attacks

The Adventist Health Study, an observational study, showed a dose-response curve for men (4). In other words, group one, which drank more than five glasses of water daily, had the least risk of death from heart disease than group two, which drank more than three glasses of water daily. Those in group three, which drank fewer than two glasses per day, saw the least amount of benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrinogen, a substance that helps clots form.

Mood and energy levels

In a study, mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women (5). In this small study the mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

I would also suggest, from my practice experience, hydration prior to exercise.

Ways to stay hydrated

Now we realize we need to stay hydrated, but how do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data, but did not find adequate studies to suggest that eight glasses is supported in the literature (6). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like Mediterranean or Dietary Approaches to Stop Hypertension (DASH), have a plant-rich focus. A study notes that diets with a focus on fruits and vegetables increases water consumption (7). As you may know, 95 percent of the weights of many fruits and vegetables are attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Is coffee dehydrating?

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (8). With moderate amounts of caffeinated beverages, the liquid has a more hydrating effect than its diuretic effect.

Thus, it is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (9).

References:

(1) Neurology. 2009 Mar 10;72(10):922-7. (2) Handb Clin Neurol. 2010;97:161-72. (3) my.clevelandclinic.org. (4) Am J Epidemiol 2002 May 1; 155:827-33. (5) J. Nutr. February 2012 142: 382-388. (6) AJP – Regu Physiol. 2002;283:R993-R1004.  (7) Am J Lifestyle Med. 2011;5(4):316-319. (8) Exerc Sport Sci Rev. 2007;35(3):135-140. (9) Br J Ophthalmol. 2005:89:1298–1301.

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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Nail fungus usually affects toenails. METRO photo
Treating nail fungus requires patience

By David Dunaief, M.D.

Dr. David Dunaief

As we begin our forays into summer public spaces, we are also beginning to expose our toes at the beach and in strappy sandals. Some are more self-conscious about it because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is also an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat, although it affects approximately eight percent of the population (2). The risk factors are unclear but may relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected (3).

Many organisms can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A potassium hydroxide (KOH) preparation can be used to differentiate them. This is important, because some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of psoriasis.

When considering treatment, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most effective, but they also have the most side effects. The treatments can take from around three months to one year. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Oral treatments

There are several oral antifungal options, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These tend to have the greatest success rate, but the disadvantages are their side effects. In a small but randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of toenail fungus with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration. Patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with the 24-week group experiencing better results.

The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked regularly while using terbinafine.

Another approach to reducing side effects is to give oral antifungals in a pulsed fashion. In an RCT, fluconazole 150 or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, efficacy still was not as great as with terbinafine or itraconazole (7).

Topical options

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, it takes approximately a year of daily use, and its efficacy is not as great as oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In one trial, ciclopirox had to be applied daily for 48 weeks in patients with mild to moderate levels of fungus.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). In a small study of 56 patients comparing laser only with laser plus topical antifungals, the best complete “cure” rates were achieved with the combination therapy, 21 percent versus 11 percent with laser only (10).

The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Partial improvement occurred in the toenails of 10 patients. The gel was applied daily for 48 weeks. The advantages are low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and a lower efficacy when compared to oral antifungals.

None of the treatments are perfect. Oral medications tend to be the most efficacious but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance.

If you decide on this approach, discuss it with your doctor and comply with precautionary tests on a regular basis, such as liver enzyme monitoring. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better choice. No matter what, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196; Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Eur J Med Res. 2018; 23: 53. (11) J Am Board Fam Med. 2011;24:69–74.

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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Focus on improving your health by making lifestyle modifications. METRO photo
The right motivators might be as important as dietary changes

By David Dunaief, M.D.

Excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis, autoimmune diseases and a host of others. Weight also has an impact on all-cause mortality and longevity.

In theory, losing weight should be simple: if we burn more kilocalories (energy) than we take in, we should lose weight. However, it is much more complicated.

Among factors that result in weight loss (or not) are stress levels. High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone (1). In this case, hormones contribute to weight gain.

It is hotly debated as to which approach is best for weight loss. Is it lifestyle changes with diet and exercise, medical management with weight loss drugs, surgical procedures or even supplements? The data show that, while medication and surgery may have their places, they are not replacements for lifestyle modifications; these modifications are needed no matter what route you follow.

But the debate continues as to which diet is best – for both weight loss and overall health. Let’s look at the evidence.

Low-carbohydrate vs. low-fat diets

Is a low-carbohydrate, high-fat diet a fad? In the publication of a 12-month randomized controlled trial (RCT), results showed that a low-carbohydrate diet was significantly better at reducing weight than low-fat diet, by a mean difference of 3.5 kg lost (7.7 lb), even though calories were similar and exercise did not change (2).

The authors also note that the low-carbohydrate diet reduced cardiovascular disease risk factors in the lipid (cholesterol) profile, such as decreasing triglycerides (mean difference 14.1 mg/dl) and increasing HDL (good cholesterol). Patients lost 1.5 percent more body fat on the low-carbohydrate diet, and there was a significant reduction in the inflammation biomarker C-reactive protein (CRP). There was also a reduction in the 10-year Framingham risk score, which estimates cardiovascular risk. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group.

There were 148 participants, predominantly women with a mean age of 47, none of whom had cardiovascular disease or diabetes, but all of whom were obese or morbidly obese (BMI 30-45 kg/m²). Although there were changes in biomarkers, there was a dearth of cardiovascular disease clinical end points, which were not investigated.

Digging deeper into the diets used, it’s interesting to note that the low-fat diet was remarkably similar to the standard American diet; it allowed 30 percent fat, only 5 percent less than the 35 percent baseline for the same group. In addition, it replaced the fat with mostly refined carbohydrates, including only 15 to 16 g/day of fiber.

The low-carbohydrate diet participants took in an average of 100 fewer calories per day than participants on the low-fat diet, so it’s no surprise that they lost a few more pounds over a year’s time.

As David Katz, M.D., founding director of Yale University’s Prevention Research Center, noted, this study was more of a comparison of low-carbohydrate diet to a high-carbohydrate diet than a comparison of a low-carbohydrate diet to a low-fat diet (3).

Diet comparisons

Interestingly, in a meta-analysis (group of 48 RCTs), results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet) was followed, there was a similar amount of weight loss compared to no intervention at all (4). Both diet types resulted in about 8 kg (17.6 lb) of weight loss at six months versus no change in diet.

In an accompanying editorial, the author points out that it is unclear whether a low-carbohydrate/high-animal protein diet might result in adverse effects on the kidneys, loss of calcium from the bones, or other potential health risks. The author goes on to say that, for overall health and longevity and not just weight loss, micronutrients found in nutrient-dense foods may be the most important factor.

A Seventh-Day Adventist trial would attest to the benefits of emphasizing a micronutrient-rich, plant-based diet with limited animal protein. It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet (5).

Psyche

Finally, the type of motivator is important, whatever our endeavors. Weight loss goals are no exception. A published study followed West Point cadets from school to many years after graduation and noted who reached their goals (6). The researchers found that internal motivators and instrumental (external) motivators were very important.

The soldiers who had an internal motivator, such as wanting to be a good soldier, were more successful than those who focused on instrumental motivators, such as wanting to become a general. Those who had both internal and instrumental motivators were not as successful as those with internal motivators alone. In other words, having internal motivators led to an instrumental consequence of advancing their careers.

When it comes to health, focusing on an internal motivator, such as increasing energy or decreasing pain, could ultimately lead to an instrumental consequence of weight loss.

There is no question that dietary changes are most important to achieving sustained weight loss. However, we need to get our psyches in line for change. Hopefully, when we choose to improve our health, we don’t just focus on weight as a measure of success. Focus on improving your health by making lifestyle modifications. This tends to result in a successful instrumental consequence.

References:

(1) Psychoneuroendocrinol. online 2014 April 12. (2) Ann Intern Med. 2014;161(5):309-318. (3) Huffington Post. Sept 2, 2014. (4) JAMA. 2014;312(9):923-933. (5) JAMA Intern Med. 2013;173:1230-1238. (6) Proc Natl Acad Sci U S A. 2014;111(30):10990-10995.

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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Deer ticks are widely known as the sole carrier of the bacteria that causes Lyme disease in humans. Stock photo
The lingering effects of Lyme can be debilitating

By David Dunaief, M.D.

Dr. David Dunaief

After a spring where we’ve spent more than our fair share of time indoors, summer’s heat is finally here. Many of us are taking advantage of the weather to enjoy day hikes and picnics along the shoreline or bike rides through wooded areas.

The summer’s heat also means that tick season is in full swing. This means we need to be aware of Borrelia burgdorferi, better known as the bacterium that causes Lyme disease. This bacterium is typically found in the deer tick, also known as the blacklegged tick.

What do deer ticks look like? They are small and can be as tiny as a pencil tip or the size of a period at the end of a sentence. The CDC.gov site is a great resource for tick images and other information related to Lyme disease.

If you have been bitten by a tick, you should remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick; doing so may spread infectious disease (1). In a study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The National Institutes of Health recommend not removing a tick with oil (2).

When a tick is removed within 36 to 48 hours, the risk of infection is quite low (3). However, a patient can be given a prophylactic dose of the antibiotic doxycycline, one dose of 200 mg, if a bulls-eye rash — a red outer ring and red spot in the center — has not occurred, and it is within 72 hours of tick removal (4). Those who took doxycycline had significantly lower risk of developing the bulls-eye rash and thus Lyme disease; however, treatment with doxycycline did sometimes cause nausea.

Lyme Symptoms

Stock photo

There are three stages of Lyme disease: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue (54 percent), muscle pain and joint pain (44 percent), headache (42 percent), neck stiffness (35 percent), swollen glands (23 percent) and fever (16 percent) (5).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory radiculoneuropathy (nerve roots of spinal cord). Late disseminated disease can cause Lyme arthritis (inflammation in the joints), heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (2).

Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death (6). If there are symptoms of chest pain, palpitations, light-headedness, shortness of breath or fainting, clinicians should suspect Lyme carditis.

Preventing Lyme

According to the Centers for Disease Control and Prevention, we should wear protective clothing, spray ourselves with insect repellent that includes at least 20 percent DEET and treat our yards (4). Always check your skin and hair for ticks after walking through a woody or tall grassy area. Many of us on Long Island have ticks in the yard, so remember to check your pets; even if treated, they can carry ticks into the house.

Diagnosing Lyme

Lyme disease often can be diagnosed within the clinical setting or with a blood test. When it comes to serologic or blood tests, the CDC recommends an ELISA test followed by a confirmatory Western blot test (3). However, testing immediately after being bitten by a tick is not useful, since the test will tend to be negative, regardless of infection or not (4). It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (5). These antibodies sometimes remain elevated even after successful treatment with antibiotics.

Does chronic Lyme disease exist?

There has been a debate about whether there is something called “chronic Lyme” disease. The research, unfortunately, has not shown consistent results that indicate that it exists. In one analysis, the authors note that the definition of chronic Lyme disease is obfuscated and that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes, according to several prospective trials (7).

The authors do recognize that there are prolonged neurologic symptoms in a subset population that may be debilitating even after the treatment of Lyme disease. These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment.

Ultimately, the IDSA (Infectious Diseases Society of America) argues in favor of recognizing post-Lyme disease syndromes, while the ILADS (International Lyme and Associated Diseases Society) believes chronic Lyme exists.

Regardless, the lingering effects of Lyme can be debilitating. This may be as a result of systemic inflammation (8). Systemic inflammation and its symptoms can be improved significantly with dietary and other lifestyle modifications.

The CDC recommends that physicians look beyond Lyme for other possible diagnoses before diagnosing someone with chronic Lyme disease (9).

Prevention is key to helping stem Lyme disease. If this is not possible, treating prophylactically when pulling off a tick is an important step. Contact your physician as soon as you notice a tick. If you have a bulls-eye rash and it is early, then treatment of antibiotics for two to three weeks needs to be started right away. If it is prolonged and disseminated, then treatment should be for approximately three to four weeks with antibiotics. If it has affected the central nervous system, then IV antibiotics could be needed.

References:

(1) Pediatrics. 1985;75(6):997. (2) nlm.nih.gov. (3) cdc.gov. (4) Clin Infect Dis. 2008;47(2):188. (5) uptodate.com. (6) MMWR. 2014;63(43):982-983. (7) Expert Rev Anti Infect Ther. 2011;9(7):787-797. (8) J Infect Dis. 2009;199(9:1379-1388). (9) JAMA Intern Med. online Nov. 3, 2014.

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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Consuming four or more servings of legumes per week has shown to reduce the risk of heart disease. Stock photo
Even small dietary changes move us closer to being ‘heart attack proof’

By David Dunaief, M.D.

Dr. David Dunaief

We can significantly reduce the occurrence of heart disease, the number one killer in the United States, by making modest lifestyle changes.

Heart disease is a term that captures a number of disorders, from coronary artery disease, which can cause heart attacks, to valve issues and heart failure, which is a problem with the pumping mechanism. Here, our focus will be on coronary artery disease and their resulting heart attacks.

According to the Centers for Disease Control and Prevention, there are 805,000 heart attacks in the U.S.  annually, and 200,000 of these occur in those who’ve already had a first heart attack (1). Here, I will provide specifics on how to make changes to protect you and your family, regardless of family history.

The evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Changes that garner a big bang for your buck include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Treat yourself – cocoa’s benefits

Preliminary evidence shows that two pieces of chocolate a week may decrease the risk of a heart attack by 37 percent, compared to those who consume less (2). However, the authors warned against the idea that more is better. In fact, high fat and sugar content and calorically dense aspects may have detrimental effects when consumed at much higher levels. There is a fine line between potential benefit and harm. The benefits may be attributed to micronutrients referred to as flavonols.

I usually recommend that patients have one to two squares – about one-fifth to two-fifths of an ounce – of high-cocoa-content dark chocolate daily. Who says prevention has to be painful?

Increase your fiber intake

Fiber has a dose-response relationship to reducing risk. In other words, the more fiber intake, the greater the reduction in risk. In a meta-analysis of 10 studies, results showed for every 10-gram increase in fiber, there was a corresponding 14 percent reduction in the risk of a cardiovascular event and a 27 percent reduction in the risk of heart disease mortality (3). The authors analyzed data that included over 90,000 men and 200,000 women.

The average American consumes about 16 grams per day of fiber (4). The Academy of Nutrition and Dietetics recommends 14 grams of fiber for each 1,000 calories consumed, or roughly 25 grams for women and 38 grams for men (5). Therefore, we can significantly reduce our risk of heart disease if we increase our consumption of fiber to reach the recommended levels. Good sources of fiber are fruits and vegetables with the edible skin or peel, beans and lentils, and whole grains.

Legumes’ impact

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (NHEFS), legumes reduced the risk of coronary heart disease by a significant 22 percent. Those who consumed four or more servings per week, compared to those who consumed less than one serving, saw this effect. The legumes used in this study included beans, peas and peanuts (6). There were over 9,500 men and women involved, spanning 19 years of follow-up.

I recommend that patients consume at least one to two servings a day, or 7 to 14 a week. Imagine the impact that could have, compared to the modest four servings per week used to reach statistical significance in this study.

A nutty solution

In a study with over 45,000 men, there were significant reductions in coronary heart disease with omega-3 polyunsaturated fatty acids (PUFAs). Both plant-based and seafood-based omega-3s showed these effects (7). Good sources of omega-3s from plant-based sources include nuts, such as walnuts, and ground flaxseed.

Your ultimate goal should be to become “heart attack proof,” a term used by Dr. Sanjay Gupta and reinforced by Dr. Dean Ornish. Ideally, this requires a plant-based diet. But even modest changes in diet will result in significant risk reductions. The more significant the lifestyle changes you make, the closer you will come to achieving this goal.

References:

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (5) eatright.org. (6) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (7) Circulation. 2005 Jan 18;111(2):157-164.

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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Stock photo
Early diagnosis is crucial to treatment success

By David Dunaief, M.D.

Dr. David Dunaief

Diabetic retinopathy is an umbrella term for microvascular complications of diabetes that can lead to blurred vision and blindness. There are at least three different disorders that comprise it: dot and blot hemorrhages, proliferative diabetic retinopathy and diabetic macular edema. The latter two are the ones most likely to cause vision loss. Our focus for this article will be on diabetic retinopathy as a whole and on diabetic macular edema, more specifically.

Diabetic retinopathy is the number one cause of vision loss in those who are 25 to 74 years old (1). Risk factors include duration of diabetes, glucose (sugar) that is not well-controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2).

What is diabetic macula edema, also referred to as DME? Its signature is swelling caused by extracellular fluid accumulating in the macula (3). The macula is the region of the eye with greatest visual acuity. A yellowish oval spot in the central portion of the retina — in the inner segment of the back of the eye —it is sensitive to light. When fluid builds up from leaking blood vessels, there is potential for vision loss.

Those with the longest duration of diabetes have the greatest risk of DME (4). Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent loss of vision (5). Herein lies the challenge.

In a cross-sectional study (a type of observational study) using NHANES data from 2005-2008, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (6). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes. Many patients are unaware of the association between vision loss and diabetes.

Treatment options                                             

While DME is traditionally treated with lasers, intravitreal (intraocular — within the eye) injections of a medication known as ranibizumab (Lucentis) may be as effective.

The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab, whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7).

Increased risk with diabetes drugs

You would think that drugs to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective (backward-looking) study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (8). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. [Note that DME is not the only side effect of these drugs. There are important FDA warnings of other significant issues.]

To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.

This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both of these studies were not without weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (10). Thus, there needs to be a prospective (forward-looking) trial done to sort out these results.

Diet

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But an inference can be made: A nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy complications (12, 13).

The best way to avoid diabetic retinopathy is obviously to prevent diabetes. Barring that, it’s to have sugars well-controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones.

References:

(1) Diabetes Care. 2014;37 (Supplement 1):S14-S80. (2) JAMA. 2010;304:649-656. (3) www.uptodate.com. (4) JAMA Ophthalmol online. 2014 Aug. 14. (5) www.aao.org/ppp. (6) JAMA Ophthalmol. 2014;132:168-173. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.

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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GERD is a common condition in which the esophagus becomes irritated or inflamed because of acid backing up from the stomach. Stock photo
You may avoid medications by making simple changes

By David Dunaief, M.D.

Dr. David Dunaief

Wherever you look there is an advertisement for the treatment of heartburn or indigestion, both of which are related to reflux disease.

Reflux typically results in symptoms of heartburn and regurgitation, with stomach contents going backward up the esophagus. For some reason, the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Of course, a portion of reflux is physiologic (normal functioning), especially after a meal (1). As such, it typically doesn’t require medical treatment.

Gastroesophageal reflux disease (GERD), on the other hand, differs in that it’s long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). Can you understand why pharmaceutical firms give it so much attention?

GERD risk factors are diverse. They range from lifestyle — obesity, smoking cigarettes and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Diet issues include triggers like spicy foods, peppermint, fried foods and chocolate.

Smoking and Salt

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Medications

The most common and effective medications for the treatment of GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Here, I will focus on PPIs, for which more than 100 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), and Prevacid (lansoprazole). They have demonstrated efficacy for short-term use in the treatment of Helicobacter pylori-induced (bacteria overgrowth in the gut) peptic ulcers, GERD symptoms and complication prevention and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

However, they are often used long-term as maintenance therapy for GERD. PPIs used to be considered to have mild side effects. Unfortunately, evidence is showing that this may not be true. Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year, not 10 years. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use are increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Bacterial infection risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

B12 deficiencies

Suppressing hydrochloric acid produced in the stomach may result in malabsorption issues if turned off for long periods of time. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. B12 was not absorbed properly from food, but the PPIs did not affect B12 levels from supplementation (9). Therefore, if you are taking a PPI chronically, it is worth getting your B12 and methylmalonic acid (a metabolite of B12) levels checked and discussing possible supplementation with your physician if you have a deficiency.

Lifestyle modifications

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the same study already mentioned with smoking and salt, fiber and exercise both had the opposite effect, reducing the risk of GERD (5). This was a prospective (forward-looking) trial. The analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (11).

Obesity

In one study, obesity exacerbated GERD. What was interesting about the study is that researchers used manometry, which measures pressure, to show that obesity increases the pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index. This is yet another reason to lose weight.

Eating close to bedtime       

Though it may be simple, it is one of the most powerful modifications we can make to avoid GERD. A study that showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime. Of note, this is 10 times the increased risk of the smoking effect (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.”

Although there are a number of ways to treat GERD, the most comprehensive have to do with modifiable risk factors. Drugs have their place in the arsenal of choices, but lifestyle changes are the first — and most effective — approach in many instances. Consult your physician before stopping PPIs, since there may be rebound hyperacidity (high acid produced) if they are stopped abruptly.

References:

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec.; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 20.0. Updated December 23, 2019. Accessed June 23, 2020. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov/safety/medwatch/safetyinformation. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar.; 130:639-649. (13) Am J Gastroenterol. 2005 Dec.;100(12):2633-2636.

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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Dairy may not be as beneficial as we have been led to believe. Stock Photo
Does calcium really reduce risk?

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis and low bone mass increase dramatically as we age. According to the Centers for Disease Control, over 48 percent of those ages 65 and older in the U.S. are affected by low bone mass, and 16.4 percent by osteoporosis (1).

Why do we care? Because they may lead to increased risk of fracture and, subsequently, lower mobility, which may have significant quality of life impacts (2). That is what we know. But what about what we think we know?

For decades we have been told that if we want strong bones, we need to consume dairy. This has been drilled into our brains since we were toddlers. Dairy has calcium and is fortified with vitamin D, so it could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that dairy may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.” We will investigate this further. Vitamin D and calcium are good for us. But do supplements help prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

Holes in the dairy paradigm

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (3). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, 3 percent per glass increased risk of death in men. Women experienced a small, but significant, increased risk of hip fracture, but no increased risk in overall fracture risk. There was no increased risk of fracture in men, but there was no benefit either. There were higher levels of biomarkers that indicate oxidative stress and inflammation found in the urine.

This study was 20 years in duration and is eye-opening. We cannot make any decisive conclusions, only associations, since it is not a randomized controlled trial. But it does get you thinking. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect, whereas other foods have many-fold lower levels of this substance.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume up to three servings of dairy per day (4). This is interesting, since the results from the previous study showed the negative effects at this recommended level of milk consumption. The USDA may want to rethink these guidelines.

Prior studies show milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (5).

Calcium disappointments

Unfortunately, it is not only milk that may not be beneficial. In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food on a daily basis (6).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of the large multivaried meta-analyses is that vitamin D baseline levels, exercise and phosphate levels were not considered.

Vitamin D benefit

Finally, though the data is not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (7). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Just because something in medicine is a paradigm does not mean it’s correct. Milk may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. Of course, the patients in these trials were not necessarily deficient in calcium or vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, patients may need at least 800 IUs per day, which is the Institute of Medicine’s recommended amount for a relatively similar population as in the study.

Remember that studies, though imperfect, are better than tradition alone. Prevention and treatment therefore should be individualized, and deficiency in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References:

(1) cdc.gov (2) JAMA. 2001;285:785-795. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (7) N Engl J Med. 2012 Aug. 2;367(5):481.

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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Over 30 million people in the United States suffer from some form of eczema. Stock Photo
Most treatments focus on managing symptoms of itchiness or redness

By David Dunaief, M.D

Dr. David Dunaief

Referred to more broadly as atopic dermatitis, the cause of eczema is unknown, but it is thought that nature and nurture are both at play (1). Eczema is a chronic inflammatory process that involves symptoms of pruritus (itching) pain, rashes and erythema (redness) (2).

Eczema is common in both children and adults. In the United States, it’s estimated that over seven percent of the adult population is afflicted (3), with twice as many females as males affected (4). Ranging in severity from mild to moderate to severe, adults tend to have moderate to severe eczema.

Treatments for eczema run the gamut from over-the-counter creams and lotions to prescription steroid creams to systemic (oral) steroids and injectable biologics. Some use phototherapy for severe cases, but the research on phototherapy is scant. Antihistamines are sometimes used to treat the itchiness. Also, lifestyle modifications may play an important role, specifically diet. Two separate studies have shown an association between eczema and fracture, which we will investigate further.

Let’s look at the evidence.

Eczema isn’t just superficial

Eczema may also be related to broken bones, according to several studies. For example, one observational study showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more disturbing 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (5). And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. One reason for increased fracture risk, the researchers postulate, is the use of corticosteroids in treatment.

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density. Chronic inflammation may also contribute to the risk of bone loss. There were 34,500 patients involved in the study, ranging in age from 18 to 85. For those who have eczema and have been treated with steroids, it may be wise to have a DEXA (bone) scan.

Supplements’ effectiveness

The thought of supplements somehow seems more appealing for some than medicine. There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective.

In a meta-analysis (involving seven randomized controlled trials, the gold standard of studies), evening primrose oil was no better than placebo in treating eczema (6). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. One positive is that these supplements only had minor side effects. But don’t look to supplements for significant help.

Injectable solutions

Dupilumab is a biologic monoclonal antibody (7). In trials, this injectable drug showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like any drug therapy, it is not without side effects, though.

Topical probiotics

When we think of probiotics, we think of taking a pill. However, there are also potentially topical probiotics with atopic dermatitis. In preliminary in-vitro (in a test tube) studies, the results look intriguing and show that topical probiotics from the human microbiome (gut) could potentially work as well as steroids (8). This may be part of the road to treatments of the future. However, this is in very early stage of development.

What about lifestyle modifications?

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (9).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (10).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15 to 20 percent of patients who suffer some level of eczema. For example, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin had all but cleared.

I also have a personal interest in eczema. I suffered from hand eczema, where my hands would become painful and blotchy and then crack and bleed. This all stopped for me when I altered my diet many years ago.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (11). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising topical probiotics ahead and medications for the hard to treat. It might be best to avoid long-term systemic steroid use; it could not only impact the skin but also may impact the bone. Lifestyle modifications appear to be very effective, at least at the anecdotal level.

References:

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) uptodate.com. (3) J Inv Dermatol. 2017;137(1):26-30. (4) BMC Dermatol. 2013;13(14). (5) JAMA Dermatol. 2015;151(1):33-41. (6) Cochrane Database Syst Rev. 2013;4:CD004416. (7) Medscape.com. (8) ACAAI 2014: Abstracts P328 and P329. (9) Allergy. 2010 Jun 1;65(6):758-765. (10) J Am Acad Dermatol. 2004;50(3):391-404. (11) Contact Dermatitis 2008; 59:43-47.

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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