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Dr. David Dunaief

New research suggests inflammation is associated with early Parkinson's disease­. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Parkinson’s disease (PD) is the second most common neurodegenerative disorder in the U.S. after Alzheimer’s disease. Estimates put the number of people living with Parkinson’s disease at up to 1.2 million, with 90,000 new diagnoses each year (1).

Patients with PD suffer from a collection of symptoms caused by the breakdown of brain neurons. There’s a lot we still don’t know about the causes of PD; however, risk factors may include head trauma, genetics, exposure to toxins and heavy metals, and lifestyle issues, like lack of exercise.

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (2). Adding back dopamine has been the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also by modifying lifestyle, considering factors like iron, vitamin D, inflammation, and CoQ10. While the research is not conclusive, it is intriguing and gives us more options.

What impact does iron have on the brain?

This heavy metal is potentially harmful for neurodegenerative diseases such as Alzheimer’s disease, macular degeneration, multiple sclerosis and, yes, Parkinson’s disease. The problem is that it can cause oxidative damage.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (3).

The chelator reduced the risk of disease progression significantly on the Unified Parkinson Disease Rating Scale (UPDRS) during the 12-month study. Participants who were treated sooner had lower levels of iron compared to a group that used the chelator six months later. A specialized MRI was used to measure the brain’s iron levels.

The iron chelator does not affect, nor should it affect, systemic levels of iron, only those in the substantia nigra region of the brain. The chelator may work by preventing degradation of the dopamine-containing neurons. Your physician may also recommend that you consume foods that contain less iron.

What is the role of inflammation in PD?

In a recent study, researchers tested 58 newly diagnosed PD participants’ blood and compared their results to 62 healthy control participants (4). Some of the PD arm participants had additional testing done, including cerebrospinal fluid samples and brain imaging. All these tests were looking for specific inflammatory markers.

Researchers found that those with PD had significantly higher brain inflammation levels than those without PD in specific regions. Their blood and cerebrospinal fluid also had high inflammatory markers. These measures correlated with worse visuospatial and cognitive scores.

While this study provides hints of possible treatments, we need additional studies to identify whether the inflammation is a cause or an effect of PD.

Regardless, adopting a low-inflammatory foods diet might help mitigate some symptoms of PD or slow its advancement.

Does CoQ10 help slow PD progression?

There is evidence that CoQ10 may be beneficial in PD at high doses.

In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to a placebo group (5). Other doses of 300 and 600 mg showed trends toward benefit, but were not significant. This was a 16-month trial in a small population of 80 patients. Unfortunately, results for other CoQ10 studies have been mixed.

In this study, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with PD.

Does Vitamin D make a difference?

Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In a prospective study of over 3000 patients, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (6). This is impressive, especially since the highest quartile patients had vitamin D levels that were what we qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less.

In an RCT with 121 patients, results showed that 1,200 IU of vitamin D taken daily may have reduced the progression of PD significantly on the UPDRS compared to a placebo over a 12-month duration (7). Also, this amount of vitamin D increased the blood levels by almost two times from 22.5 to 41.7 ng/ml. 

In a 2019 study of 182 PD patients and 185 healthy control subjects, researchers found that higher serum vitamin D levels correlated to reduced falls and alleviation of other non-motor PD symptoms (8).

Vitamin D research is ongoing, as this all seems promising.

So, what are our takeaways? Though medication is the gold standard for Parkinson’s disease treatment, lifestyle modifications can have a significant impact on both its prevention and treatment. Each lifestyle change in isolation may have modest effects, but cumulatively their impact could be significant.

References:

(1) parkinson.org. (2) uptodate.com. (3) Antioxid Redox Signal. 2014;10;21(2):195-210. (4) Movement Disorders. 2023;38;5:743-754. (5) Arch Neurol. 2002;59(10):1541-1550. (6) Arch Neurol. 2010;67(7):808-811. (7) Am J Clin Nutr. 2013;97(5):1004-1013. (8) Neurologica. 2019;140(4):274-280.

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

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We know better. So why can’t we do better?

By David Dunaief, M.D.

Dr. David Dunaief

We are continuously inundated with messages about the importance of including fruits and vegetables in our daily diets. In addition to fiber, they include critical nutrients and micronutrients that keep us healthy and reduce our risks of developing chronic diseases.

Despite this, according to a 2022 report by the Centers for Disease Control and Prevention (CDC), an average of 12.3 percent of U.S. adults met the daily requirements for fruit intake, and an even more abysmal 10 percent met vegetable intake recommendations (1). As you might expect, it follows that we are deficient in many key micronutrients (2).

Why do we care? Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients. 

Here’s a stunning statistic: more than 50 percent of American adults have a chronic disease, with 27 percent having more than one (3). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade and are currently at around 77 years old.

One indicator of nutrient intake that we can measure is carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. I measure these regularly, because they give me a sense of whether the patient might lack potentially disease-fighting nutrients. A high nutrient intake dietary approach can resolve the situation and increase both carotenoid and other critical nutrient levels.

Why focus on a high nutrient intake diet?

A high nutrient intake diet focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals — plant nutrients. Micronutrients are bioactive compounds found mostly in foods and in some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum of them is greater than their parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (4).

A 20 percent increase in diet scores, which indicated an improved quality of diet, was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent more than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large, prospective cohort study, where the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

How can diet improve your quality of life?

Quality of life is as important as longevity. Let’s examine some studies that consider the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (6). The authors attribute this effect, at least partially, to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. Each tablespoon of olive oil contains 120 calories, all of them fat. If you eat too much of even good fat, it can be counterproductive. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s.

In a case-control study that compared those with and without disease, high intake of antioxidants from food was associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), the leading cause of blindness in those 55 years or older (7). This was true even when participants had a genetic predisposition for the disease.

There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can improve our outcomes. With a focus on a high nutrient intake diet, we can improve life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. Morb Mortal Wkly Rep 2022;71:1–9. (2) cdc.gov/nutritionreport (3) cdc.gov. (4) N Engl J Med 2017; 377:143-153. (5) BMJ. 2009;338:b2337. (6) Neurology June 15, 2011. (7) Arch Ophthalmol. 2011;129(6):758-766.

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

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Lowering your sodium intake can help

By David Dunaief, M.D.

Dr. David Dunaief

Although it’s possible to have a kidney stone without symptoms, more often they present with the classic symptoms of blood in the urine and colicky pain. The pain can be intermittent or constant, and it can range from dull to extremely painful, described by some as being worse than giving birth, being shot or being burned. The pain can radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1).

Stones are usually diagnosed through the symptoms and either abdominal x-rays or non-contrast CT scans.

Unfortunately, the first line treatment for passing kidney stones — at least small ones — involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are smaller than four millimeters pass spontaneously. Stones closest to the opening of the urethra are more likely to pass through on their own (2).

Generally, if you’ve passed a kidney stone, you know it.

In the case of a stone too large to pass naturally, a urologist may use surgery, ultrasound, or a combination of methods to break it into smaller pieces, so you can pass it. Unfortunately, once a patient forms one stone, the possibility of having others increases significantly over time. The good news is that there are several lifestyle changes you can make to reduce your risk.

How much water do you need to drink?

First, it is very important to stay hydrated and drink plenty of fluids, especially if you have a history of stone formation (3). You don’t have to rely on drinking lots of water to accomplish this, though. Increasing your consumption of fruits and vegetables that are moisture-filled can help, as well.

Do supplements play a role in stone formation?

One of the simplest methods is to reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones. Calcium oxalate is the dominant one, occurring approximately 80 percent of the time (4). Calcium supplements, therefore, increase the risk of kidney stones.

When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (5). According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (6). It did not matter whether study participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, calcium from dietary sources actually has the opposite effect, decreasing risk. In the same study, those participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest group. Paradoxically, calcium intake shouldn’t be too low, either, since that also increases kidney stone risk. Changing your source of calcium is an important key to preventing kidney stones.

What role does sodium play in stone formation?

Again, in the Nurses’ Health Study, participants who consumed 4.5 grams of sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 grams per day (6). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Does protein play a role in stone formation?

Animal protein may play a role. In a five-year, randomized clinical trial, men who reduced their consumption of animal protein to approximately two ounces per day, as well as lowering their sodium, were 51 percent less likely to experience a kidney stone than those who consumed a low-calcium diet (7). These were men who had histories of stone formation.

The reason animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that animal protein’s higher sulfur content produces more acid. This acid is neutralized by release of calcium from the bone (8). That calcium can then promote kidney stones.

Does blood pressure impact kidney stones?

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (9). Amazingly, it did not matter whether or not the patients were treated for high blood pressure with medications; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not just the symptoms. The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more that you implement, the lower your likelihood of stones.

References:

(1) emedicine January 1, 2008. (2) J Urol. 2006;175(2):575. (3) J Urol. 1996;155(3):839. (4) N Engl J Med. 2004;350(7):684. (5) Kidney Int 2003;63:1817–23. (6) Ann Intern Med. 1997;126(7):497-504. (7) N Engl J Med. 2002 Jan 10;346(2):77-84. (8) J Clin Endocrinol Metab. 1988;66(1):140. (9) BMJ. 1990;300(6734):1234.

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

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Increasing dietary fiber can make a big difference

By David Dunaief, M.D.

Dr. David Dunaief

We all have hemorrhoids. They’re vascular structures that help control our stool. When they become irritated and inflamed, we often say we “have hemorrhoids.” What we really mean is that our hemorrhoids are causing us pain.

Many of us have suffered at one time or another from hemorrhoid pain. They affect men and women equally, though women have a higher propensity during pregnancy and childbirth.

When our hemorrhoids are irritated, we may experience itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They often bleed, especially during a bowel movement, which can be scary. Fortunately, hemorrhoids are not a harbinger of more serious disease.

There are two types of hemorrhoids: external, occurring outside the anus; and internal, occurring within the rectum.

Treating external hemorrhoids

Fortunately, external hemorrhoids tend to be mild. Most of the time, we can treat them with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H. 

Another treatment option is a sitz bath.  All of these can help relieve the pain. Because we can treat them with over-the-counter solutions, external hemorrhoids generally do not require a doctor’s appointment.

For a more comprehensive solution, the most effective way to reduce this bleeding and pain is to increase your fiber intake with dietary changes and supplementation (1). 

Sometimes, however, there is thrombosis (clotting) of external hemorrhoids. In these cases, they may become more painful and require medical treatment.

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should consult your physician to confirm it is not due to a malignancy or other cause, such as inflammatory bowel disease.

Treating internal hemorrhoids

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since the hemorrhoids are usually above the point of sensation in the colon, called the dentate line. If there is pain and discomfort, it’s generally because the internal hemorrhoids have prolapsed, or fallen out of place, due to weakening of the muscles and ligaments in the colon. This allows them to fall below the dentate line.

The first step for treating internal hemorrhoids is the same as for external hemorrhoids: add fiber through diet and supplementation. Study after study shows significant benefit. For instance, in a meta-analysis by the Cochrane Systems Data Review 2005, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, daily incidence of bleeding decreased dramatically (3).

What are the treatments for persistent hemorrhoid pain?

There are several minimally invasive options to address persistent and painful hemorrhoids, including banding, sclerotherapy and coagulation. The most effective of these is banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where rubber bands are placed at the neck of each hemorrhoid to cut off the blood flow. To avoid complications from constipation, patients should also take fiber supplementation. Side-effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgery) would be the next option.

How do you prevent hemorrhoid problems?

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, which can increase the risk of inflammation. Though you may want private time to read, the bathroom is not the library. As soon as you have finished moving your bowels, it is important to get off the toilet.

Get plenty of fluids. This helps soften the stool and prevent constipation. Exercise also helps prevent constipation. You should not hold in a bowel movement; go when the urge is there, or the stool can become hard, resulting in straining, constipation, and more time on the toilet.

How do I get more fiber?

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining.

Americans, on average, consume 16g per day of fiber (5). The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 to 38 grams, depending on gender and age (6). I typically recommend at least 40 grams. My wife and I try to eat only foods that contain a significant amount of fiber, and we consume approximately 65 grams a day.

You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned – side-effects are potentially gas and bloating for the first week or two.

I generally recommend adjusting your diet before reverting to supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes all have significant amounts of fiber. Grains, beans and nuts have among the highest levels of fiber. For instance, one cup of black beans has 12g of fiber.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-6. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-7. (4) Dis Colon Rectum 2004 Aug;47(8):1364-70. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85.

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

Symptoms of diverticular disease include fever and abdominal pain. METRO photo
Physical activity and fiber make a difference

By David Dunaief, M.D.

Dr. David Dunaief

Diverticular disease, or diverticulosis, becomes more common as we age. In the U.S., more than 30 percent of those aged 50-59 are affected and, for those over 80, approximately 70 percent are affected (1).

The good news is that modest lifestyle changes can potentially prevent it. Here, I will explain simple ways to reduce your risk, while also debunking a pervasive myth — that fiber, or more specifically nuts and seeds, exacerbates the disease.

What causes diverticular disease? 

Diverticular disease is a weakening of the lumen, or wall of the colon, which results in the formation of pouches or out-pocketing referred to as diverticula. Pressure from constipation may be part of the cause. 

Its mildest form, diverticulosis may be asymptomatic. In other cases, symptoms may include fever and abdominal pain, predominantly in the left lower quadrant in Western countries, or the right lower quadrant in Asian countries. It may need to be treated with antibiotics.

Diverticulitis affects 10 to 25 percent of those with diverticulosis. Diverticulitis is inflammation and infection, which may lead to a perforation of the bowel wall. Emergency surgery may be required if a rupture occurs.

Unfortunately, the incidence of diverticulitis is growing. In 2010, about 200,000 were hospitalized for acute diverticulitis, and roughly 70,000 were hospitalized for diverticular bleeding (2). For those between 40 and 49 years old, the incidence of diverticulitis grew 132 percent between 1980 and 2007, the most recent data on this population (3).

How do you prevent diverticular disease and its complications? 

There are several modifiable risk factors, including diet composition and fiber intake, along with weight and physical activity.

In a study that examined lifestyle risk factors for diverticulitis incidences, adhering to a low-risk lifestyle reduced diverticulitis risk almost 75 percent among men (4). The authors defined a low-risk lifestyle as including fewer than four servings of red meat a week, at least 23 grams of fiber a day, two hours of vigorous weekly activity, a body mass index of 18.5–24.9 kg/m2, and no history of smoking. They estimated that a low-risk lifestyle could prevent 50 percent of diverticulitis cases.

How do we know fiber helps?

A prospective study published online in the British Medical Journal extolled the value of fiber in reducing the risk of diverticular disease (5). This study was part of the EPIC trial, which involved over 47,000 people living in Scotland and England. It showed a 31 percent reduction in risk in those who were vegetarian.

But more intriguing, participants who had the highest fiber intake saw a 41 percent reduction in diverticular disease. Those participants in the highest fiber group consumed more than 25.5 grams per day for women and more than 26.1 grams per day for men, whereas those in the lowest group consumed fewer than 14 grams per day. Though the difference in fiber between the two groups was small, the reduction in risk was substantial.

Another study, which analyzed data from the Million Women Study, a large-scale UK study of middle-aged women, confirmed the correlation between fiber intake and diverticular disease, and further analyzed the impact of different sources of fiber (6). The authors’ findings were that reduction in the risk of diverticular disease was greatest with high intake of cereal and fruit fiber.

Most Americans get about 16 grams of fiber per day. The Institute of Medicine (IOM) recommends daily fiber intake for those under age 50 of 25-26 grams for women and 38 grams for men (7). Interestingly, their recommendations are lower for those who are over 50.

What if you consumed at least 40 grams of fiber per day? This is what I recommend for my patients. Some foods that contain the most fiber include nuts, seeds, beans and legumes. In a 2009 study, those men who specifically consumed the most nuts and popcorn saw a protective effect from diverticulitis (8).

Does obesity have an effect?

In the large, prospective male Health Professionals Follow-up Study, body mass index played a significant role, as did waist circumference (9). Those who were obese (BMI >30 kg/m²) had a 78 percent increased risk of diverticulitis and a greater than threefold increased risk of a diverticular bleed compared to those who had a BMI in the normal range of <21 kg/m². For those whose waist circumference was in the highest group, they had a 56 percent increase risk of diverticulitis and a 96 percent increase risk of diverticular bleed. Thus, obesity puts patients at a much higher risk of diverticulosis complications.

Does physical activity make a difference?

Physical activity is critical for reducing diverticular disease risk, although the exact mechanism is not yet understood. Regardless, the results are impressive. In a large prospective study, those with the greatest amount of exercise were 37 percent less likely to have diverticular disease compared to those with the least amount (10). Jogging and running seemed to have the most benefit. When the authors combined exercise with fiber intake, there was a dramatic 256 percent reduction in diverticular disease risk.

If you are focused on preventing diverticular disease and its complications, lifestyle modifications may provide the greatest benefit.

References:

(1) www.niddk.nih.gov. (2) Clin Gastroenterol Hepatol. 2016; 14(1): 96–103.e1. (3) Gastroenterology. 2019;156(5): 1282-1298. (4) Am J Gastroenterol. 2017; 112: 1868-1876. (5) BMJ. 2011; 343: d4131. (6) Gut. 2014 Sep; 63(9): 1450–1456. (7) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85. (8) AMA 2008; 300: 907-914. (9) Gastroenterology. 2009;136(1): 115. (10) Gut. 1995;36(2): 276.

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

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Increase fruits, vegetables and whole grains and eliminate processed meats

By David Dunaief, M.D.

Dr. David Dunaief

For many of us, Independence Day launches a long string of summer barbecues. What if you could use these to kick-start your path to better health?

In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are barbecue and picnic staples. But there are healthier alternatives. If we lean into alternatives, like those found in a Mediterranean-style diet, we can improve our health while enjoying mouth-watering dishes.

The Mediterranean-style diet includes green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of fish and olive oil. The options are far from tasteless.

At a memorable family barbecue, we had an array of succulent choices. These included a three-bean salad, mandarin orange salad with mixed greens and a light raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon fillets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable shish kebobs, and a large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence that explains why these foods help us.

Cancer prevention

A systematic review initially published in 2016 and updated in 2017 provides a comprehensive look at the results of studies focused on weighing the effects of adherence to a Mediterranean-type diet on cancer risk and progression (1, 2). When the authors pooled and analyzed cohort studies and randomized control trials, they found an inverse relationship between cancer mortality risk and high adherence to the diet. This means that the more compliant participants were, the lower their risk of cancer mortality.

When making the same comparison between high adherence and low adherence from studies of specific cancers, they identified risk reductions for colorectal (17 percent), prostate (four percent), gastric (27 percent), and liver cancers (42 percent) (1). Further study also found high adherence reduced the risks of breast, head and neck, gallbladder, and biliary tract cancer (2).

The authors note that, while it’s improbable that any single component of the diet resulted in these effects, they were able to demonstrate significant inverse correlations between specific food groups and overall cancer risk. For example, the higher the regular consumption of fruits, vegetables, and whole grains, the lower the risk. All three of these fit right in at an outdoor feast!

Looking more closely at specific cancers, another study found that increased consumption of fruits and vegetables may help prevent pancreatic cancer. This is critical, since by the time there are symptoms, often the cancer has spread to other organs (3). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and non-citrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (4). Interestingly, cooked vegetables, not just raw ones, had a substantial effect.

Diabetes treatment and prevention

Fish might play an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of fish and seafood intake had a substantial decrease in risk of type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood. Therefore, there is nothing wrong with some grilled fish on the “barbie” to help protect you from developing diabetes.

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial, mixed nuts led to a substantial reduction of hemoglobin A1C, a very important biomarker for sugar levels for the previous three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease.

The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke prevention

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial.

Though these are promising results, I caution you to use no more than one tablespoon of olive oil per day, since it’s calorically dense. 

It is not difficult to substitute the beneficial Mediterranean-style diet for processed meats, or at least add them to the selection. This plant-based diet can help you prevent many chronic diseases. So, this Independence Day and beyond, plan to include some delicious, healthy choices.

References:

(1) Curr Nutr Rep. 2016; 5: 9–17. (2) Nutrients. 2017 Oct; 9(10): 1063. (3) Nature. 2010;467:1114-1117. (4) Cancer Causes Control. 2010;21:493-500. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-11. (7) Neurology. 2011 Aug 2;77(5):418-25.

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

Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

June is cataract awareness month. How much do you know about how to reduce your risk?

A cataract is an opacity or cloudiness of the lens in the eye, which decreases vision over time as it progresses. Typically, it’s caused by oxidative stress, and it’s common for both eyes to be affected. As we get older, the likelihood we will have cataracts that affect our vision increases.

In the U.S., 24.4 million people over the age of 40 were afflicted in 2015, according to statistics gathered by the National Eye Institute of the National Institutes of Health (1). Approximately 50 percent of Americans have cataracts by age 75.

Cataract prevalence varies considerably by gender, with 61 percent of cases being women, and by race; 80 percent of those affected are white. Chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity can contribute to your risk. 

The good news is that we can take an active role in preventing them. Protecting your eyes from the sun and injuries, quitting smoking, and increasing your consumption of fruits and vegetables can improve your odds. Here, we will focus on the dietary factor.

How does meat consumption affect cataract risk?

Diet has been shown to have substantial effect on the risk reduction for cataracts (2). One of the most expansive studies on cataract formation and diet was the Oxford (UK) group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

There was an inverse relationship between cataract risk and the amount of meat consumed. In other words, those who ate more meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork. These results followed what we call a dose-response curve.

Compared to high meat eaters, every other group demonstrated a significant risk reduction as they progressed along a spectrum that included low meat eaters (15 percent reduction), fish eaters (21 percent reduction), vegetarians (30 percent reduction) and finally vegans (40 percent reduction).

There really was not that much difference in meat consumption between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. This suggests that you can realize a meaningful effect by reducing or replacing your average meat intake, rather than eliminating meat from your diet.

In my clinical experience, I’ve had several patients experience cataract reversal after they transitioned to a nutrient-dense, plant-based diet. This is a very positive outcome and was confirmed by their ophthalmologists.

Do antioxidants help prevent cataracts?

Oxidative stress is one of the major contributors to cataract development. In a review article that looked at 70 different trials for the development of cataract and/or maculopathies, such as age-related macular degeneration, the authors concluded antioxidants, which are micronutrients found in foods, play an integral part in eye disease prevention (3). The authors go on to say that a diet rich in fruits and vegetables, as well as lifestyle modification with cessation of smoking and treatment of obesity at an early age, help to reduce the risk of cataracts. You are never too young or too old to take steps to protect your vision.

Among antioxidant-rich foods studied that have shown positive effects is citrus. The Blue Mountains Eye Study found that participants who had the highest dietary intake of vitamin C reduced their 10-year risk for nuclear cataracts (4).

How effective is cataract surgery?

The only effective way to treat cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens. This is an outpatient procedure and usually takes about 30 minutes. Fortunately, there is a very high success rate for this surgery. So why is it important to avoid cataracts if surgery can remedy them?

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage, age-related macular degeneration (AMD) after cataract surgery (5). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients.

It has been hypothesized that the surgery may induce inflammatory changes and the development of leaky blood vessels in the retina of the eye. However, this meta-analysis was based on observational studies, so it’s not clear whether undiagnosed AMD may have existed prior to the cataract surgery, since they have similar underlying causes related to oxidative stress.

If you can reduce the risk of cataracts through diet and other lifestyle modifications, plus avoid potential consequences from cataract surgery, all while reducing the risk of chronic diseases, why not choose the win-win scenario?

References:

(1) nei.nih.gov. (2) Am J Clin Nutr. 2011 May; 93(5):1128-1135. (3) Exp Eye Res. 2007; 84: 229-245. (4) Am J Clin Nutr. 2008 Jun; 87(6):1899-1305. (5) Ophthalmology. 2003; 110(10):1960.

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

Eating potassium-rich foods may improve your outcomes. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension, also commonly called “high blood pressure,” is pervasive in the U.S., affecting approximately 47 percent of adults over 18 (1). Since 2017, hypertension severity has been categorized into three stages, each with its recommended treatment regimen. 

One of the most interesting shifts with this recategorization was the recategorization of what we used to call “prehypertension” into what we now call “elevated” blood pressure and “hypertension stage 1.” 

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg, while Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of 80-89 mmHg (2). A simple chart of all levels can be found on The American Heart Association’s website at www.heart.org.

Both elevated blood pressure and stage 1 hypertension have significant consequences, even though there are often no symptoms. For example, they increase the risks of cardiovascular disease and heart attack dramatically.

In an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (3). This is why it’s crucial to address it, even in these early stages.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (4).

The good news is that, over the last decade, new and extended studies have given us better clarity about treatments, stratifying approaches to ensure the best outcomes.

Do you need to treat elevated blood pressure?

In my view, it would be foolish not to treat elevated blood pressure. Updated treatment recommendations, according to the Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, include lifestyle modifications (5).

Lifestyle changes include dietary changes. A Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet are both options. It’s important to focus on fruits, vegetables, sodium reduction to a maximum of 1500 mg (2/3 of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (6). 

Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (7). Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

Some drugmakers advocate for using medication with those who have elevated blood pressure. The Trial of Preventing Hypertension (TROPHY) suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (8)(9). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Still, the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, which makes the drug. 

In an editorial, Jay I. Meltze, M.D., a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (10). 

Elevated blood pressure has been shown to respond well to lifestyle changes – so why add medication when there are no long-term benefits? I don’t recommend treating elevated blood pressure patients with medication. Thankfully, the JNC8 agrees.

Do lifestyle changes help with Stage 1 hypertension?

For those with Stage 1 hypertension, but with a low 10-year risk of cardiovascular events, these same lifestyle modifications should be implemented for three-to-six months. At this point, a reassessment of risk and blood pressure should determine whether the patient should continue with lifestyle changes or needs to be treated with medications (11). 

It’s important to note that your risk should be assessed by your physician.

I am encouraged that the role of lifestyle modifications in controlling hypertension has been recognized and is influencing official recommendations. When patients and physicians collaborate on a lifestyle approach that drives improvements, the side effects are only better overall health.

References:

(1) cdc.gov. (2) heart.org. (3) Stroke 2005; 36: 1859–1863. (4) Hypertension 2006;47:410-414. (5) Am Fam Physician. 2014 Oct 1;90(7):503-504. (6) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (7) Archives of Internal Medicine 2001;161:589-593. (8) N Engl J Med. 2006;354:1685-1697. (9) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (10) Am J Hypertens. 2006;19:1098-1100. (11) Hypertension. 2021 Jun;77(6):e58-e67.

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

METRO photo
We should be more concerned about fiber than protein.

By David Dunaief, M.D.

Dr. David Dunaief

Growing up, I often heard admonitions to get enough protein. Even now, I am often asked how to be sure someone is getting enough. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets.

What we should be more concerned about is whether we’re getting enough fiber in our diets. Most Americans are woefully deficient in fiber, consuming between 10 and 15 grams per day. Consumption of legumes and dark green vegetables are the lowest in comparison to other fiber subgroups (1). This has significant implications for our overall health and weight.

So, how much is enough? USDA guidelines stratify their recommendations based on gender and age. For adult women, they recommend between 22 and 28 grams per day, and for adult men, the targets are between 28 and 35 grams (1). Some argue that even these recommendations are on the low end of the scale for optimal health.

Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to increase your fiber consumption; you just have to be aware of which foods are fiber-rich.

Does fiber type make a difference?

One of the complexities is that there are a number of different classifications of fiber, from soluble to viscous to fermentable. Within each of the types, there are subtypes of fiber. Not all fiber sources are equal.

At a high level, we break dietary fiber into two overarching categories: soluble and insoluble. Soluble fibers slow digestion and nutrient absorption and make us feel fuller for longer. Sources include oats, peas, beans, apples, citrus fruits, flax seed, barley and psyllium. On the other hand, insoluble fibers accelerate intestinal transit, which promotes digestive health. Sources include wheat bran, nuts, berries, legumes and beans, dark leafy greens, broccoli, cabbage and other vegetables. 

Many plant-based foods contain both soluble and insoluble fiber, in varying amounts.

Fiber’s effects on disease progression and longevity

Fiber has powerful effects on our overall health. A very large prospective cohort study showed that fiber may increase longevity by decreasing mortality from cardiovascular disease, respiratory diseases and other infectious diseases (2). Over a nine-year period, those who ate the most fiber were 22 percent less likely to die than those in the lowest group.

Patients who consumed the most fiber also saw a significant decrease in mortality from cardiovascular disease, respiratory diseases and infectious diseases. The authors of the study believe that it may be the anti-inflammatory and antioxidant effects of whole grains that are responsible for the positive results.

A study published in 2019 that performed systematic reviews and meta-analyses on data from 185 prospective studies and 58 clinical trials found that higher intakes of dietary fiber and whole grains provided the greatest benefits in protecting participants from cardiovascular diseases, type 2 diabetes, and colorectal and breast cancers, along with a 15-30 percent decrease in all-cause mortality for those with the highest fiber intakes, compared to those with the lowest (3).

We also see benefit with prevention of chronic obstructive pulmonary disease (COPD) with fiber in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities study (4). The specific source of fiber was important. Fruit had the most significant effect on preventing COPD, with a 28 percent reduction in risk. Cereal fiber also had a substantial effect, but it was not as great.

Fiber also has powerful effects on breast cancer treatment. In a study published in the American Journal of Clinical Nutrition, soluble fiber had a significant impact on breast cancer risk reduction in estrogen negative women (5). Most beneficial studies for breast cancer have shown results in estrogen receptor positive women. This is one of the few studies that has illustrated significant results in estrogen receptor negative women.

The list of chronic diseases and disorders that fiber prevents and/or treats is continually expanding.

How do I increase my fiber intake?

Emphasize plants on your plate. Animal products don’t contain natural fiber. These days, it’s easy to increase your fiber by choosing bean- or lentil-based pastas, which are becoming more prevalent in general grocery stores. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice.

If you are trying to prevent chronic diseases in general, I recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages: it helps you avoid processed foods, reduces your risk of chronic disease, and increases your satiety and energy levels.

Certainly, while protein is important, each time you sit down at a meal, rather than asking how much protein is in it, you now know to ask how much fiber is in it.

References:

(1) USDA.gov. (2) Arch Intern Med. 2011;171(12):1061-1068. (3) Lancet. 2019 Feb 2;393(10170):434-445. (4) Amer J Epidemiology 2008;167(5):570-578. (5) Amer J Clinical Nutrition 2009;90(3):664–671.

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

Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

Our assumptions about alcohol and health are complicated and often wrong. Many of you may have heard that Europeans who drink wine regularly live longer because of this. Or that only heavy drinkers need to be concerned about long-term health impacts. Would it surprise you to hear that both assumptions have been studied extensively?

Alcohol is one of the most widely used over-the-counter drugs, and yet there is still confusion over whether it benefits or harms to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing, including cancers, heart disease and stroke.

Alcohol and cancer risk

The National Cancer Institute notes that alcohol is listed as a known carcinogen by the National Toxicology Program of the US Department of Health and Human Services (1). Among the research it details, it lists head and neck, esophageal, breast, liver and colorectal cancers as key cancer risks that are increased by alcohol consumption. Of these, esophageal and breast cancer risks are increased with even light drinking. Let’s look more closely at some of the research on breast cancer risk that supports this.

A meta-analysis of 113 studies found there was an increased risk of breast cancer with daily alcohol consumption (2). The increase was a modest, but statistically significant, four percent, and the effect was seen at one drink or fewer a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increased the risk of breast cancer modestly over a 28-year period (3). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, meaning the more participants drank in a day, the greater their risk increase. In this study, there was no difference in risk by type of alcohol consumed, whether wine, beer or liquor.

Based on what we think we know, if you are going to drink, a drink a few times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes this effect (4).

Alcohol and stroke risk

On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (5). This analysis involved over 83,000 women. Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

However, women who consumed more experienced a decline in benefits, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients should not drink alcohol solely to get stroke protection benefits.

If you’re looking for another option to achieve the same benefits, an analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (6). The citrus fruits used most often in this study were oranges and grapefruits. Note that grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (7).

Alcohol and heart attack risk

In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more and those who were non-drinkers (8). Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits.

What’s the conclusion?

Moderation is the key. It is important to remember that alcohol is a drug, and it does have side effects, including insomnia. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more. To achieve the stroke benefits and avoid increased breast cancer risk, half a glass of alcohol per day may work for women. For men, up to two glasses daily counts as moderate, though one glass showed significant general health benefits. 

If you choose to forgo alcohol, the good news is that there is a growing variety of non-alcoholic beverages entering the market and increasing in popularity.

References:

(1) cancer.gov. (2) Alc and Alcoholism. 2012;47(3)3:204–212. (3) JAMA. 2011;306:1884-1890. (4) JAMA. 2011;306(17):1920-1921. (5) Stroke. 2012;43:939–945. (6) Stroke. 2012;43:946–951. (7) Medscape.com. (8) Eur Heart J. Published online March 28, 2012.

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