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Dr. David Dunaief

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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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As a general goal, aim for at least 30 minutes of moderate physical activity every day. METRO photo
Low inflammation may play a significant role in healthy aging

By David Dunaief, M.D.

Dr. David Dunaief

What does it mean to you to “grow old gracefully?” For people I speak with, it means to be independent, mobile, mentally alert, and not burdened by chronic illnesses. In other words, to maintain a good quality of life.

The number of 90-year-olds is growing by leaps and bounds. According to the National Institutes of Health, those who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those aged 85 and older.

What do these people have in common? According to one study, they tend to have fewer chronic morbidities or diseases. Thus, they tend to have a better quality of life with a greater physical functioning and mental acuity (2).

In a study of centenarians, genetics played a significant role. Characteristics of this group were that they tended to be healthy and then die rapidly, without prolonged suffering (3).

Factors that predict one’s ability to reach this exclusive club may involve both genetics and life-style choices. Let’s look at the research.

Exercise

We are told time and time again to exercise. But how much do we need, and how can we get the best quality? In a 2014 study, the results showed that 5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular mortality and all-cause mortality (4).

Amazingly, even if participants ran fewer than six miles per week at a pace slower than 10-minute miles, and even if they ran only one to two days a week, there was still a decrease in mortality compared to nonrunners. Here is the kicker: Those who ran for this very short amount of time potentially added three years to their life span. There were 55,137 participants ranging in age from 18 to 100 years old.

An accompanying editorial to this study noted that more than 50 percent of people in the United States do not meet the current recommendation of at least 30 minutes of moderate exercise per day (5).

Diet

A long-standing paradigm has been that we need to eat sufficient animal protein. However, cracks have developed in this theory, especially as it relates to longevity. In an observational study using NHANES III data, results show that those who ate a high-protein diet (greater than 20 percent from protein) had a twofold increased risk of all-cause mortality, a four-times increased risk of cancer mortality and a four-times increased risk of dying from diabetes (6). This was over a considerable duration of 18 years and involved almost 7,000 participants ranging in age at the start of the study from 50 to 65.

However, this did not hold true if the protein source was plants. In fact, a high-protein plant diet may reduce the risks, not increase them. The reason, according to the authors, is that animal protein may increase insulin growth factor-1 and growth hormones that have detrimental effects on the body.

Interestingly, those who are over age 65 may benefit from more animal protein in reducing the risk of cancer. However, there was a significantly increased risk of diabetes mortality across all age groups eating a high animal protein diet. The researchers therefore concluded that lower animal protein may be wise at least during middle age.

The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein up to once a week had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (7). This was an observational trial with over 73,000 participants and a median age of 57 years old.

Inflammation

In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ longevity (8). In fact, if participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.

The takeaway from this study is that IL-6 is a relatively common biomarker for inflammation that can be measured with a simple blood test offered by most major laboratories. This study involved 3,044 participants over the age of 35 who did not have a stroke, heart attack or cancer at the beginning of the study.

The bottom line is that, although genetics are important for longevity, so too are lifestyle choices. A small amount of exercise, specifically running, can lead to a substantial increase in healthy life span. 

Protein from plants may trump protein from animal sources in reducing the risk of mortality from all causes, from diabetes and from heart disease. This does not necessarily mean that one needs to be a vegetarian to see the benefits. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Therefore, why not have a discussion with your doctor about testing to see if you have an elevated IL-6? Lifestyle modifications may be able to reduce these levels.

References:

(1) nia.nih.gov. (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) J Am Coll Cardiol. 2014;64:472-481. (5) J Am Coll Cardiol. 2014;64:482-484. (6) Cell Metab. 2014;19:407-417. (7) JAMA Intern Med. 2013;173:1230-1238. (8) CMAJ. 2013;185:E763-E770.

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

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Studies show that modest wine consumption may reduce cardiovascular risks. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

By now, we have all likely heard that soda – with 39 grams of sugar per 12-ounce can – is associated with an increased risk of diabetes. Bur did you know that wine has a very low amount of sugar: about 1.2 grams of sugar in a five-ounce serving? Even more surprising, it may have benefits in reducing complications associated with diabetes.

Why is this important? The current rate of diabetes among the U.S. adult population is 12.2 percent, while another 84 million U.S. adults have prediabetes (HbA1C of 5.7-6.4 percent) (1).

For those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (2).

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

Diet vs. metformin for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, this is not an optimal diabetes diet.

I’ll drink to that!

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (4).

Patients were randomized into three groups, each receiving a drink with dinner nightly; one group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Blood pressure medications’ surprising results

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (5). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a good, but nonideal, diet had better results, in comparison to medication. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Ann Intern Med. 2015;163(8):569-579. (5) Diabetologia. Online Sept. 23, 2015.

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

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Studies have shown 50 percent fewer cardiac events with CoQ10 supplementation. Stock photo
Supplementation may improve outcomes

By David Dunaief, M.D.

Dr. David Dunaief

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

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

There are about 6.5 million Americans with heart failure (1), and heart failure contributed to one in eight deaths in 2017 (2).

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

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

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

Effect of diet

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

In a population-based, prospective (forward-looking) study, called the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (3). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

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

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

CoQ10 supplementation

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

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

The lead author goes as far as to suggest that CoQ10 should be part of the paradigm of treatment. This the first new “drug” in over a decade to show survival benefits in heart failure.

A meta-analysis involving 13 studies of CoQ10 supplementation with HF confirmed that CoQ10 resulted in ejection fraction improvements among patients with less severe stages of HF, although the authors suggest that studies with more diverse demographics and that refine and compare dose responses are warranted (5).

Thus, if you have heart failure, you may want to discuss CoQ10 with your doctor.

Iron deficiency

Anemia and iron deficiency are not synonymous, since iron deficiency can occur without anemia. A recent observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (6).

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

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

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

References:

(1) Circulation. 2019;139(10):e56–528. (2) cdc.gov. (3) Am J Med. 2013 Jun:126(6):494-500. (4) JACC Heart Fail. 2014 Dec;2(6):641-649. (5) Am J Clin Nutr. 2013 Feb; 97(2): 268–275. (6) Am Heart J. 2013;165(4):575-582.

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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To reduce binge eating, take the dog for a walk while social distancing. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Obesity is an ongoing struggle for many in the United States. The latest statistics suggest that 40 percent of the population is obese. Obesity is a disease unto itself and is defined by a BMI (body mass index) of >30 kg/m2, but obesity can also be defined by excess body fat, which is more important than BMI.

Obesity has been associated with COVID-19, especially in the U.S. In a study involving 5700 hospitalized COVID-19 patients in the NYC area, the most common comorbidities were obesity, high blood pressure and diabetes (1). Of those who were hospitalized, 41.7 percent were obese.

In a study in China, results showed that those who were overweight were 86 percent more likely to have severe COVID-19 pneumonia, and that percentage increased to 142 percent when obesity is reached (2). The study has yet to be peer-reviewed, but it complements other studies.

Another study from France indicates that those with a BMI >35 (severely obese), were more likely to be put on ventilators (3).

In fact, one study’s authors suggested quarantining should be longer in obese patients because of the potential for prolonged viral shedding compared to those in the normal range for weight (4). And though age is a risk factor for COVID-19, among those younger than 60 and obese, there is a two-times increased risk of being admitted to the hospital, according to a 3,615-patient study at NYU Langone Health (5).

Why are you at higher risk for severe COVID-19 with obesity? 

According to the prevailing theory, obesity may interfere with mechanical aspects of breathing, thus increasing airway resistance and make gas in exchange more difficult in the lung. It may also impede on lung volume by exerting pressure on the lungs and may involve weaker muscles necessary for respiration (6).

Why is excess fat more important than BMI? 

First, some who have elevated BMI may not have a significant amount of fat; they may actually have more innate muscle. More than 25 percent of my patient population is “solidly built,” which means they have greater muscle mass as well as too much excess fat. (I have a body analysis scale that detects muscle mass and fat through two different currents of ohms.) Visceral fat is the most important, since it’s the fat that lines the organs, including the lungs.

For another, fat cells have adipokines, specific cell communicators found in fat cells that communicate with other fat cells but also other systems such as the brain, immune system, muscles, and liver. Adipokines can be mediators of both inflammation and insulin resistance, according to an en-docrinology study (7). In a study of over 4,000 patients with COVID-19, the author suggests that inflammation among obese patients may be an exacerbating factor for hospitalizations and severe illness (8). 

If we defined obesity as being outside the normal fat range – normal ranges are roughly 11-22 per-cent for men and 22-34 percent for women – then close to 70 percent of Americans are “obese.”

Inflammation reduction and weight-loss combined

In a randomized controlled trial with 75 participants comparing a plant-based diet to a control diet, there was a greater than 14 lbs. weight reduction and roughly 10 lbs. fat reduction over a 14-week period (9). Of the weight lost, about 70 percent was excess fat. Remember, excess body fat, through adipokines, may be inflammatory and increase the risk of severe COVID-19. 

The weight reduction with a plant-based approach may involve the increase in fiber, reduction in dietary fat and increased burning of calories after the meal, according to Physician’s Committee for Responsible Medicine (PCRM) (10).

You also want a diet that has been shown to reduce inflammation.

We are currently submitting a small study for publication involving 16 patients from my clinical practice. It shows that those who ate a whole food plant-based LIFE (low inflammatory foods every-day) diet over a seven-day period had a significant decrease in inflammation measured by hsCRP (high sensitivity c-reactive protein). This occurred in those who completely changed their diets to the LIFE diet, but also occurred in those who simply added a greens and fruit-based smoothie daily to their existing diet.

In my practice, I have seen a number of patients lose a substantial amount of weight, but also excess body fat, over a short period. For instance, a 70-year-old male lost 19 lbs. of weight and 12 lbs. of excess body fat over a six-week period. His inflammation, which was very high to start, dropped substantially to the border of optimal levels, using hsCRP as the inflammation measurement. This patient and many others have seen tandem reductions in both weight and inflammation. To boot, this was a cardiac patient whose cardiologist had considered a stent, but later said he did not need it after reducing his inflammation.

Exercise to reduce binge eating

While sheltering in place with fewer physical activities available, it is very tempting to binge eat or use food as a leisure activity. But there is a way around this. 

In patients who are overweight and obese, those who exercised compared to those who were sedentary, showed a significant reduction in binge eating over a 12-week intervention (11). The participants at baseline had a mean BMI of 30.6 kg/m2 and a mean age of 43 years. Of the 46 participants, almost two-thirds were women. Exercise can be as easy as walking or running outside while social distancing; doing exercises with your own body weight, such as calisthenics; taking online exercise classes (of which there are plenty); or using exercise equipment you have at home, might help allay binge eating.

If COVID-19 does not convince you that losing excess body fat is important, then consider that obesity contributes to, or is associated with, many other chronic diseases like cardiovascular disease, high blood pressure, and high cholesterol, which also contribute to severe COVID-19. Thus, there is an imperative to lose excess body fat. Now, while we’re sheltering in place, is the time to work on it.

References:

(1) JAMA. online April 22, 2020. (2) https://doi.org/10.2139/ssrn.3556658 (2020). (3) Obesity. online April 9, 2020. (4) Acta Diabetol. 2020 Apr 5: 1–6. (5) Clin Infect Dis. Online April 9, 2020. (6) Chron. Respir. Dis. 5, 233–242 (2008). (7) Front Endocrinol (Lausanne). 2013; 4:71. (8) MedRxiv.com. (9) Nutr Diabetes. 2018; 8: 58. (10) Inter Journal of Disease Reversal and Prevention 2019;1:1. (11) Med Sci Sports Exerc. 2020;52(4):900-908.

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

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Foods that comfort the mind and body protect you from chronic diseases in the long term. Stock photo
Focusing on real ‘comfort food’ will improve your outcomes

By David Dunaief, M.D.

Dr. David Dunaief

I think it’s fair to say that our world has been radically altered by the current COVID-19 pandemic. If you are at home weathering this storm, it can feel like you are in a literal silo. 

So naturally, we need to find things that make us feel “better.” Many of us reach for food to help comfort us. Guess which food item has had the largest sales increase in the U.S. from 2019. Here is a hint: it’s not broccoli. It’s frozen cookie dough, where sales are up 454 percent (1). 

But there is a difference between food that comforts just the mind and food that comforts both the mind and the body. What is the difference? Let’s look at two recent examples from my clinical practice. 

Food that comforts the mind and body 

Stock photo

First, let’s look at the results of a 71-year-old male who stopped eating out during COVID-19, like so many of us. Apparently, for this patient, eating out meant indiscretions with his diet. While at home, there was less temptation to stray from his dietary intentions. The results speak for themselves. 

In a month, his nutrient level improved, measured using serum beta carotene levels. His inflammation, measured by c-reactive protein (CRP), was reduced 40 percent. What is the importance of inflammation? It is the potential basis for many of the chronic diseases that are rampant in the U.S. (2). His kidney function increased by about 14 percent with an increase in his glomerular filtration rate (GFR), which helps remove waste from the kidney, from 51 to 58. This patient, who suffers from gout, also found his uric acid dropped. Finally, and most importantly, his symptoms improved, and he garnered more energy. He described himself as enjoying food more.

I am not suggesting you don’t order out, but do it wisely. Diametrically opposed is our second example. 

Food that comforts the mind only

Stock photo

This 72-year-old female decided to embrace ultra-processed foods, adding cookies, cakes and sour-dough breads to her diet. Her kidney function decreased by more than 15 percent, with the GFR shifting from 88 to 63. Her inflammation, measured by CRP, went up by 75 percent. Her LDL, “bad cholesterol,” increased by more than 20 percent. Her allergy symptoms worsened. She described herself as more sluggish and, to boot, she gained five pounds.

What makes these examples even more interesting is that both patients are deemed in the high-risk category for getting severe COVID-19 and being hospitalized. COVID-19 is associated with elevated CRP, which may increase the risk for more lung lesions and the risk of severe disease (3).

What is the moral of the story? Use this time to focus on foods that comfort both the mind and the body. Make food work for you and against the common enemies of COVID-19 and chronic diseases that are putting people at higher risk for viruses.

What about exercise? 

Just because we are cooped up indoors most of the time does not mean we can’t exercise. Time and again, exercise benefits have been shown. Yet, we are sitting more and, with social distancing, we have less incentive to go outside or opportunities to socialize, go to the gym or do many of our usual activities.

However, not to fret. There was a recent small study with eight volunteers equally split between men and women. Results showed that four-minute intervals of exercise throughout the day that interrupted continuous sitting led to a substantial improvement in triglycerides and metabolized more fat after high-fat meals the next day, compared to continuous sitting for eight hours uninterrupted and then eating a high fat meal the next day (4).  

The participants used a stationary bike, exercising intensely for four seconds and then resting for 45 seconds, repeating the sequence five times in a row. They completed this four-minute sequence once an hour for eight hours. Their daily intense exercise totaled 160 seconds. This bodes well for very short bursts of exercise rather than sitting for long periods without movement.

Not everyone has a stationary bike, but you can do jumping jacks, run in place, or even dance vigorously to your favorite tunes once an hour.

Ventilator vs. Incentive Spirometer

As I’m sure you’ve been reading, some with severe COVID-19 require ventilators. Unfortunately, the statistics with ventilators are dismal. According to a recent study of 5700 COVID-19 patients in the New York region, 88.1 percent of patients died (5). Hospitals are trying alternate approaches while using oxygen masks not ventilators, such as proning (turning patients on their stomach instead of lying on their backs in bed) and having them sit up in a chair in order to help with oxygenation in the lungs in those who have low oxygen saturation.

However, the ultimate exercise for the lung and the ability to improve oxygenation is an incentive spirometer. This device expands your lungs as you inhale. The more you do it, the better your lung functioning. One study, which I mentioned in previous articles on lung function, involved inhaling a total of 50 breaths a day which in two increments (6). 

The brand of spirometer used was a Teleflex Triflo II. This costs less than five dollars online at medicalvitality.com

What about incentive spirometer in sick patients? There was a small study with patients who had COPD exacerbations (7). Those who were given an incentive spirometer plus medical treatment saw a significant increase in the blood gases over a two-month period. Also, the quality of life improved for those using the incentive spirometer. 

Remember, one of the factors that may be a sign that someone is at high risk for severe COVID-19 is very low oxygen saturation. If you can improve oxygen saturation with incentive spirometer that is readily available, how can you pass this up? 

While it is tempting to gorge yourself with food that comforts the mind, DON’T! Foods that comfort the mind and the body protect you not only in the short term, but also the longer term from the consequences of chronic diseases.

Therefore, focus on DGLV (dark green leafy vegetables) that raise beta-carotene, which in turn lowers CRP. This can be achieved with diet by increasing consumption of beta-carotene-rich fruits and vegetables while limiting consumption of beta-carotene-poor ultra-processed and fatty foods. Interestingly, it is much easier right now to get DGLVs than it is to get certain ultra-processed foods. Add in exercise and an incentive spirometer and you will comfort your body plus your mind.

References:

(1) CNBC.com April 23,2020. (2) Front Immunol. 2018; 9: 1302. (3) Med Mal Infect. 2020 Mar 31;S0399-077X(20)30086-X. (4) Medicine & Science in Sports & Exercise. Online April 17, 2020. (5) JAMA. 2020 Apr 22;e206775. (6) Ann Rehabil Med. Jun 2015;39(3):360-365. (7) Respirology. 2005 Jun;10(3):349-53. 

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

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Symptoms of OSA include loud snoring. Stock photo
Difficult-to-control high blood pressure may be a sign of OSA

By David Dunaief, M.D.

Dr. David Dunaief

Sleep is a crucial factor for our physical and mental health, yet many people struggle to get quality restful sleep. For those with obstructive sleep apnea (OSA), this occurs frequently and can lead to consequences more significant than exhaustion.

Sleep apnea is an abnormal pause in breathing that occurs at least five times an hour while sleeping and can be caused by either airway obstruction (OSA), brain signal failure (central sleep apnea), or a combination of these two (complex sleep apnea). There are a surprising number of people in the United States with sleep apnea. Its prevalence may be as high as 20 percent of the population (1). 

Here, our focus is on OSA, which can be classified as either mild, moderate or severe. It’s estimated that 80 percent of moderate and severe OSA are undiagnosed.

Risk factors for OSA include chronic nasal congestion, large neck circumference, excess weight or obesity, alcohol use, smoking and a family history. Not surprisingly, about two-thirds of OSA patients are overweight or obese. Smoking increases risk threefold, while nasal congestion increases risk twofold (2). Fortunately, many of the risk factors are modifiable.

Significant symptoms of OSA include daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration and morning headaches. These symptoms, while significant, are not the worst problems. OSA is also associated with a list of serious complications, such as cardiovascular disease, high blood pressure and cancer.

There are several treatments for OSA. Among them are continuous positive airway pressure (CPAP) devices; lifestyle modifications, including diet, exercise, smoking cessation and reduced alcohol intake; oral appliances; and some medications.

Cardiovascular disease

In an observational study, the risk of cardiovascular mortality increased in a linear fashion to the severity of OSA (3). In other words, in those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death; and in the severe group, this risk jumped considerably, 250 percent. However, the good news is that treating patients with CPAP considerably decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients. This study involved 1,116 women over a six-year duration.

Not to leave out men, another observational study showed similar risks of cardiovascular disease with sleep apnea and benefits of CPAP treatment (4). There were more than 1,500 men in this study with a follow-up of 10 years. The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in stemming these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA 38 and 125 percent, respectively (5). But, just like in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

Though all three studies were observational, it seems that OSA affects both genders and all ages when it comes to increased risk of cardiovascular disease and death, and CPAP may be effective in reducing these risks.

Cancer association

In sleep apnea patients under 65 years old, a study showed an increased risk of cancer (6). The authors believe that intermittent low levels of oxygen, which are caused by the many frequent short bouts of breathing cessation during sleep, may be responsible for the development of tumors and their subsequent growth.

The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. So, for those patients with more than 12 percent low-oxygen levels at night, there is a twofold increased risk of cancer development, when compared to those with less than 1.2 percent low-oxygen levels.

Sexual function

It appears that erectile dysfunction may also be associated with OSA. CPAP may decrease the incidence of ED in these men. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspect of this study was that, at baseline, the participants were overweight, not obese, on average and were young, at 45 years old. In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

Dietary effect

Although CPAP can be quite effective, it may not be well tolerated by everyone. In some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or may be used in combination with CPAP.

In a small study, a low-energy diet showed positive results in potentially treating OSA. It makes sense, since weight loss is important. But even more impressively, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year. Patients studied were those who suffered from moderate-to-severe levels of sleep apnea. Low-energy diet implies a low-calorie approach, such as a diet that is plant-based and nutrient-rich.

The bottom line is that if you think you or someone else is suffering from sleep apnea, it is very important to go to a sleep lab to be evaluated, and then go to your doctor for a follow-up. Don’t suffer from sleep apnea and, more importantly, don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are effective treatments for this disorder, including diet and CPAP.

References:

(1) sleepapnea.org. (2) JAMA. 2004;291(16):2013. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) Am J Respir Crit Care Med. 2012 Nov. 15. (7) APSS annual meeting: abstract No. 0574. (8) BMJ. 2011;342:d3017.

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

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Photo from METRO
Immune system regulation is complex and involves over 1,000 genes

By David Dunaief, M.D.

Dr. David Dunaief

Autoimmune diseases affect more than seven percent of the U.S. population, most of them women. More than 80 conditions have autoimmunity implications (1). Among the most common are rheumatoid arthritis (RA), lupus, thyroid (hypo and hyper), psoriasis, multiple sclerosis and inflammatory bowel disease. 

In all autoimmune diseases, the immune system inappropriately attacks organs, cells and tissues of the body, causing chronic inflammation. Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others.

Drug treatments

The mainstay of treatment is immunosuppressives. In RA, where there is swelling of joints bilaterally, a typical drug regimen includes methotrexate and TNF (tumor necrosis factor) alpha inhibitors, like Remicade (infliximab). These therapies seem to reduce underlying inflammation by suppressing the immune system and interfering with inflammatory factors, such as TNF-alpha. Disease-modifying anti-rheumatic drugs (DMARDs), a class that also includes Plaquenil (hydroxychloroquine), may slow or stop the progression of joint destruction and increase physical functioning.

However, there are several concerning factors with these drugs. First, the side effect profile is substantial. It includes the risk of cancers, opportunistic infections and even death, according to black box warnings (the strongest warning by the FDA) (3). Opportunistic infections include diseases like tuberculosis and invasive fungal infections.

It is no surprise that suppressing the immune system would result in increased infection rates. Nor is it surprising that cancer rates would increase, since the immune system helps to fend off malignancies. In fact, a study showed that after 10 years of therapy, the risk of cancer increased by approximately fourfold with the use of immunosuppressives (4).

Tangentially, there is also concern that these drugs might make those who contract COVID-19 more susceptible to severe symptoms and consequences. On the flip side, some are being studied to determine whether they can improve outcomes for others by suppressing immune system overreactions. 

Second, these drugs were tested and approved using short-term randomized clinical trials, but many patients are prescribed these therapies for 20 or more years. 

So, what other methods are available to treat autoimmune diseases? These include medical nutrition therapy using bioactive compounds, which have immunomodulatory (immune system regulation) effects on inflammatory factors and on gene expression and supplementation.

Nutrition and inflammation

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. While I have not found studies that specifically tested diet in RA treatment, there is a study that looked at the Mediterranean-type diet in 112 older patients where there was a significant decrease in inflammatory markers, including CRP (5).

In another study, participants showed a substantial reduction in CRP with increased flavonoid levels, an antioxidant, from vegetables and apples. Astaxanthin, a carotenoid found in fish, was shown to significantly reduce a host of inflammatory factors in mice, including TNF-alpha (6).

Fish oil

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (7). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory, such as NFkB.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (8). When treating patients with autoimmune disease, I typically suggest about 2 grams of EPA plus DHA to help regulate their immune systems. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood thinning effects.

Probiotic supplements

The gut contains approximately 70 percent of your immune system. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (9, 10).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor, TNF-alpha (11). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Fiber

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (12).

In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (13).

Immune system regulation is complex and involves over 1,000 genes, as well as many biomarkers. Dysfunction results in inflammation and potentially autoimmune disease. We know the immune system is highly influenced by bioactive compounds found in high nutrient foods and supplements. Therefore, bioactive compounds may work in tandem with medications and/or may provide the ability to reset the immune system through immunomodulatory effects and thus treat and prevent autoimmune diseases.

*Especially in this time of COVID-19, do not alter your medications, in other words, stop or start medications, without discussing it with your physician first. It is much more important to control the autoimmune disease than tot worry about drug effects on the immune system. 

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Am J Clin Nutr. 2009 Jan;89(1):248-256. (6) Chem Biol Interact. 2011 May 20. (7) Am J Clin Nutr. 2009 Aug;90(2):415-424. (8) Drugs. 2003;63(9):845-853. (9) Gut. 2003 Jul;52(7):975-980. (10) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (11) Gut. 2002;51(5):659. (12) Arch Intern Med. 2007;167(5):502-506. (13) Nutr Metab (Lond). 2010 May 13;7:42.

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

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Photo from METRO
Who benefits from stronger lungs? EVERYONE!

By David Dunaief, M.D.

Dr. David Dunaief

Until recently, many people thought COVID-19 was like the common cold or maybe like the flu. Now, most of us know somebody directly or indirectly who has been hospitalized with COVID-19. 

While social distancing and handwashing are critical to prevent its spread, strengthening lung function is crucial to preventing its progression to severe disease.

Among those with highest risk for severe COVID-19 are those with chronic obstructive lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma, as well as those who smoke and vape.

What can we do to strengthen our lungs? We can improve lung function with simple lifestyle modifications including exercising, eating a plant-based diet with a focus on fruits and vegetables, expanding lung capacity with an incentive spirometer, and quitting smoking and vaping, which damage the lungs (1). Not only people with compromised lungs will benefit; studies suggest “healthy” people will also benefit.

Why is this important?

This virus starts in the throat but may progress to the lungs attacking the alveoli, small air sacs that allow gas exchange to take place. When this occurs, patients get short of breath and may have to be hospitalized and placed on a ventilator. Two factors influence this: inflammation and fluid in the lungs.

Both asthma and COPD increase inflammation of the airways and the lung’s functional tissue (parenchyma) thus, potentially making these patients more susceptible to severe COVID-19.

Let’s look at the research, taking a three-pronged, or “forked,” approach: diet, incentive spirometry and exercise.

Diet Studies in Asthma

In a randomized controlled trial (gold standard of studies) of asthma patients, results show that after 14 days those who ate a low-antioxidant diet had less lung function compared to those who ate a high-antioxidant diet (2). Researchers measured lung function with one-second forced expiratory volume (FEV1) and predicted forced vital capacity (FVC). Additionally, those who were in the low-antioxidant diet group also had higher inflammation at 14 weeks, as measured using a c-reactive protein (CRP) biomarker. Those who were in the low-antioxidant group also were over two-times more likely to have an asthma exacerbation.

The good news is that the difference in behavior between the high- and low-antioxidant groups was small. The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Carotenoid supplementation, instead of antioxidant foods, made no difference in inflammation. The authors concluded that an increase in carotenoids from diet have a clinically significant impact on asthma and can be seen in a very short period. 

Diet Studies in COPD

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers. Bear with me, because the studies were done with men or women, not both at the same time. In one study of men, for example, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (3). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain, essentially a whole foods plant-based diet. The high-fiber group was still below the American Dietetic Association-recommended 38 grams per day. This is within our grasp. 

In another study, women had a highly significant 37 percent decreased risk of COPD among those who consumed at least 2.5 serving of fruit per day compared to those who consumed less than 0.8 servings per day (4).

The highlighted fruits shown to reduce COPD in both men and women included apples, bananas, and pears.

Incentive Spirometry

What is an incentive spirometer? It’s a device that helps expand the lungs by inhaling through a tube and causing a ball or multiple balls to rise. This opens the alveoli and may help you breathe better. 

Incentive spirometry has been used for patients with pneumonia, those who have chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (5). 

A small study showed that those who trained with an incentive spirometer for two weeks increased their vital capacity, right and left chest wall motion, and right diaphragm motion. This means it improved lung function and respiratory motion. Participants were 10 non-smoking healthy adults who were instructed to take five sets of five deep breaths twice a day, totaling 50 deep breaths per day. The brands used in the study are easily accessible, such as Teleflex’s Triflo II.

In another small, two-month study of 27 patients with COPD, the incentive spirometer improved blood gasses, such as partial pressure carbon dioxide and oxygen, in COPD patients with exacerbation (6). The authors concluded that it may improve quality of life for COPD patients.  

Exercise Studies 

Photo from METRO

Exercise can have a direct impact on lung function. In a study involving healthy women ages 65 years and older, results showed that 20 minutes of high-intensity exercise three times a day improved FEV1 and FVC, both indicators of lung function, in as little as 12 weeks (7). Participants began with a 15-minute warm-up, then 20 minutes of high-intensity exercise on a treadmill, followed by 15 minutes of cool-down with stretching.

What is impressive is that it was done in older adults, not those in their twenties and not in elite athletes. Since most of us don’t have access to a treadmill right now, note that any physical exercise will be beneficial. 

We should be working to strengthen our lungs, regardless of COVID-19. However, to potentially reduce our risk of severe COVID-19, this three-pronged approach of lifestyle modifications – diet, exercise and incentive spirometer – may help without expending significant time or expense. As Yogi Berra would say, “When you come to a fork in the road, take it!” There is no time to waste.

References:

(1) Public Health Rep. 2011 Mar-Apr; 126(2): 158-159. (2) Am J Clin Nutr. 2012 Sep;96(3):534-43. (3) Epidemiology Mar 2018;29(2):254-260. (4) Int J Epidemiol Dec 1 2018;47(6);1897-1909. (5) Ann Rehabil Med. Jun 2015;39(3):360-365. (6) Respirology. Jun 2005;10(3):349-53. (7) J Phys Ther Sci. Aug 2017;29(8):1454-1457. 

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

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METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

We need help, and we need it fast. Not just for COVID-19, but also for diabetes, for the combination of the two is much worse than either disease alone. Type 2 diabetes can have devastating effects that can potentially result in patients dying prematurely from cardiovascular complications (1). COVID-19 symptoms can range from asymptomatic to severe or result in death.

Now combine diabetes with COVID-19 and you are at much higher risk of severe viral symptoms that require hospitalization and ICU admission. According to the CDC, about one-third ICU patients infected with COVID-19 have diabetes (2). 

Keeping patients out of the hospital

We know containment is critical to control COVID-19, but it’s equally important to get ahead of the mitigation of symptoms curve; we need to control the chronic diseases that exacerbate the virus’s severity. And Type 2 diabetes is one of the largest contributors. 

We can treat and reverse diabetes by empowering patients with lifestyle changes, especially diet. This is such an issue that the Mexican Deputy Minister of Health recently alluded to the fact that poor diet over at least the last 4 decades has resulted in more diabetes and obesity making people much more susceptible to COVID-19 and progressing to severe COVID-19 (3). 

It is tempting while staying at home for most of the day to want reach for comfort foods. Don’t do it. In fact, take the opposite approach and improve your diet. A whole food plant-based (WFPB) diet has been shown time and time again to prevent, treat and reverse diabetes potentially resulting in patients getting off their drugs and achieving levels that are considered normoglycemic, or non-diabetic. 

Let’s look at the evidence. 

Treating and reversing diabetes

Drugs help treat glucose, or sugar levels, and help reduce the risk of microvascular diseases such as diabetic retinopathy (eye disease causing blindness); nephropathy (kidney disease); and peripheral neuropathy, which can result in amputation. A few medications can even reduce macrovascular risk, or cardiovascular disease. Still, diet is still the best tool we have for reversing diabetes overall, with only beneficial side effects.

With COVID-19, those whose glucose is not under control are at highest risk of severe disease that results in a progression from hospitalization to ICU and the need for a ventilator to increased mortality risk. High sugars may have negative impacts on the white blood cells, which makes patients more susceptible to infection from viruses (4).

Medications’ impact

Diabetes medication alone can help control sugars, but it can’t reverse diabetes. In fact, studies with medication alone may actually increase the risk of death from polypharmacy, or too many medications. In the ACCORD trial, patients were put on an average of four diabetes medications. Researchers stopped the trial early after 3.5 years, because of a 22 percent increased rate of mortality (5). Patients did not reach their HbA1C (a three-month sugar reading) target of under 6.0 percent, because the increased death rate occurred at around 6.5. This was a large randomized controlled clinical trial with 10,251 patients, a mean age of 62.2 years, and mean HbA1C of 8.1 at baseline. 

Reversing Type 2 diabetes: plant-based dietary approach

On the other hand, studies with a WFPB diet, have shown significant reduction in sugars and potential reversal of diabetes. These include a small retrospective study and small randomized clinical trial comparing a WFPB diet to the American Diabetes’ (ADA) recommended diet. 

In a small retrospective study, the results showed a reduction of HbA1C from 8.2, which was a similar baseline as with the ACCORD trial, to 5.8 (6). Remember, the goal of the ACCORD trial was to get patients below a HbA1C of 6.0. These results occurred over a mean of seven months. In addition, patients were able to stop all of their diabetes medications and reduce their total number of medications from four to one.  The side effect was better health with a significant reduction in high blood pressure to normal levels, as well.

The weakness of this study was that it was retrospective (looking backward in time), only had 13 patients, and there was no control arm. However, it suggests that this type of diet is powerful to reduce and reverse type 2 diabetes. The foods used in the nutrient-dense WFPB diet included a non-starchy vegetable-rich approach, with an emphasis on dark green leafy vegetables, whole fruits, beans, and limiting grains, especially refined grains, and limiting starchy vegetables such as sweet potatoes, winter squashes, corn and pumpkin. 

In a larger study, results showed that a high fiber diet in patients with type 2 diabetes and hypertension significantly reduced HbA1C, fasting glucose, systolic (top number) blood pressure, branchial-ankle pulse wave velocity, serum cholesterol and waist-to-hip ratio, ultimately reducing the risk of cardiovascular disease (7). The participants were considered to be having high fiber if they increased their consumption 20-25 percent above recommended daily allowances. The fiber came from foods, not supplements, including vegetables, fruits, beans and whole grains. There were 200 participants over a six-month duration. 

A third study, which was a randomized controlled trial comparing the 2003 American Diabetes Association (ADA) diet to a low-fat vegan diet showed that a low-fat vegan diet significantly reduced the HbA1C compared to the 2003 ADA diet in a 74-week study (8). There were 99 type 2 diabetes patients in the study. A “side effect” of the low-fat vegan diet was that it also significantly reduced cholesterol. 

Preventing diabetes

There have been numerous studies demonstrating that a WFPB diet reduces the risk of diabetes. One of the best was the Adventist Health Study 2 (9). The results showed that a vegan diet reduced the risk of type 2 diabetes by 49 percent. This study is interesting because the different groups were very similar and it showed that small changes could have a big impact. Semi-vegetarians, pesco-vegetarians, and lacto-ovo vegetarians all had a reduced risk of diabetes compared to plant-focused non-vegetarians, but not as much as vegans. 

In a more recent study, results showed a 30 percent reduction in the risk of type 2 diabetes for those who ate a predominantly whole food plant-based diet including fruits, vegetables and whole grains (10). Participants were still eating some animal protein daily. This was over a 2-to-28 year period in a metanalysis involving nine observational trials.

In conclusion, the best way to reduce your risk of severe COVID-19 is to control and reverse chronic disease. Type 2 diabetes is one of the most common chronic diseases that may contribute to getting COVID-19 and progressing to a severe form. A nutrient-dense WFPB diet has been shown to potentially reverse type 2 diabetes. While you are mostly housebound, empower yourself by taking action to reduce your risk of getting COVID-19 and especially the severe disease. We have the tools: it starts with what you put on your plate.

References:

(1) Lancet 389(10085):2239–2251. (2) CDC.gov. (3) Reuters.com April 4, 2020. (4) Medscape.com March 18, 2020. (5) NEJM 2008;358:2545-2559. (6) OJPM 2012;2(3):364-371. (7) ACC Middle East Conference 2019 Presentation. (8) Am J Clin Nutr.2009 May; 89(5): 1588S–1596S. (9) Diabetes Care. 2009;32:791–796. (10) JAMA Int. Med. Online July 22, 2019.

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

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