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Dr. David Dunaief

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Bone health. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

The medical community doesn’t universally agree about the value of milk and dairy consumption for preventing osteoporosis and fractures later in life. The prevalence of osteoporosis in the U.S. is increasing as the population ages. If you are over 50, your risk for osteoporosis should be on your radar. Fifty percent of women and 25 percent of men will break a bone due to osteoporosis in their lifetimes, according to the Bone Health & Osteoporosis Foundation (1).

Hip fractures are most concerning, because they increase mortality risk dramatically. In addition, more than 50 percent of hip fracture survivors lose the ability to live independently (2).

Does dairy consumption make a difference for osteoporosis risk?

The importance of drinking milk for strong bones has been drilled into us since we were toddlers. Milk has calcium and is fortified with vitamin D, so milk could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that milk may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.”

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

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, three percent per glass increased risk of death in men. For both men and women, biomarkers that indicate higher levels of oxidative stress and inflammation were found in the urine.

This 20-year study was eye-opening. We cannot make any decisive conclusions, only associations, since it’s not a randomized controlled trial. It does get you thinking, though. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume about three cups of dairy per day (4).

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

In a 2020 meta-analysis of an array of past studies, researchers concluded that increased consumption of milk and other dairy products did not lower osteoporosis and hip fracture risks (6).

Does calcium supplementation reduce risk?

We know calcium is a required element for strong bones, but do supplements really prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food daily (7).

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

Does supplementing vitamin D reduce risk?

Finally, though the data are not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (8). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those who were 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Where does that leave us?

Our knowledge of dietary approaches is continually evolving. Milk and dairy may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. However, the patients in these trials were not necessarily deficient in calcium nor vitamin D.

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

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

References:

(1) www.bonehealthandosteoporosis.org. (2) EndocrinePractice. 2020 May;26(supp 1):1-46. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Crit Rev Food Sci Nutr. 2020;60(10):1722-1737. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

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

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We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. METRO photo
Soy puts less stress on the kidneys than animal protein

By David Dunaief, M.D.

Dr. David Dunaief

There are many myths about managing type 2 diabetes that circulate. Fortunately, our understanding of diabetes management is continually advancing, and some older guidance deserves to be retired. Let’s review a few common myths and the research that debunks them.

Should fruit be limited or avoided?

Fruit in any form, whether whole, juiced, or dried, has been long considered taboo for diabetes patients. This is only partly true.

Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. This includes dates, raisins, and apple juice, which are often added to “no sugar” foods to sweeten them. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience sugar level spikes, whether they limit whole fruits or consume an abundance (1). In a different study, whole fruit was shown to actually reduce the risk of type 2 diabetes (2).

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

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

Do all carbohydrates raise your sugars?

Fiber is one type of carbohydrate that has distinct benefits. We know fiber is important for reducing risk for a host of diseases and for managing their outcomes. This is also true for type 2 diabetes. 

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

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

Should you avoid soy when you have diabetes?

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

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

This is very important, since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism and low iodine levels should be cautious about soy consumption, since some studies suggest it might interfere with synthetic thyroid medications’ effectiveness (8).

Is bariatric surgery a good alternative to changing my diet?

Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (9). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, even with bariatric surgery, altering diet and exercise are critical to maintaining long-term benefits.

We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. Emphasizing a plant-based diet focused on whole fruits, vegetables, beans and legumes can improve your outcomes. If you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order to sustain its benefits.

References:

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Thyroid. 2006 Mar;16(3):249-58. (9) Obes Surg. 2014;24:437-455.

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

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Kidney health. METRO photo
Walking routinely can reduce your risk of dialysis

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that 37 million U.S. adults have chronic kidney disease (CKD) and that roughly 90 percent of them don’t know they have it (1).

This seems like a ridiculous number. How can this happen? It’s because CKD tends to be asymptomatic, initially. Only in the advanced stages do symptoms become evident, although there can be vague symptoms in moderate stages such as fatigue, malaise and loss of appetite. Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease. But those are only the ones at highest risk.

Why is CKD a concern?

Your kidneys function as efficient little blood filters. As I mentioned last week, they remove wastes, toxins and excess fluid from the body. In addition, they play roles in controlling blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in the blood.  

When they’re not operating at full capacity, the consequences can be heart disease, stroke, anemia, infection and depression, among others.

According to the U.S. Preventive Services Task Force and the American College of Physicians, those who are at highest risk should be screened regularly, including patients with diabetes or hypertension (2)(3). 

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

Does basic exercise help?

The results of a study show that walking reduces the risk of death by 33 percent and the need for dialysis by 21 percent (4).

Those who walked more often saw greater results. So, the participants who walked one-to-two times a week had a 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a more impressive 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. There were 6,363 participants with an average age of 70, who were followed for an average of 1.3 years.

How does protein intake affect CKD?

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

Should you limit sodium consumption?

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

Are some high blood pressure medications better than others?

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

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

Should you take NSAIDs?

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

What should I remember here?

It’s critical to protect your kidneys, especially if you have hypertension, diabetes, or a family history of kidney disease. Fortunately, basic lifestyle modifications can help; lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options. Talk to your physician about your medications — both prescription and over-the-counter — and about whether you need regular screening. High-risk patients with hypertension or diabetes should definitely be screened; however, those with vague symptoms of lethargy, aches and pains might benefit, as well.

References:

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

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

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Vegetables and fruits.
Dietary changes can help control or reverse chronic kidney disease

By David Dunaief, M.D.

Dr. David Dunaief

Your kidneys are workhorses; they perform an array of critical functions for you. Primarily, they filter waste and fluid from your body and maintain your blood’s health. They also help control your blood pressure, make red blood cells and vitamin D, and control your body’s acid levels.

When your kidney function degrades, it can lead to hypertension or cardiovascular problems and it may require dialysis or a kidney transplant in later stages. For the best outcomes, it’s critical to identify chronic kidney disease (CKD) early and adopt techniques to stop its advance. However, of the estimated 37 million U.S. adults who have CKD, as many as 9 in 10 are not aware they have it (1).

One of the challenges with identifying early-stage CKD is that symptoms are not obvious and can be overlooked. Among them are high blood pressure, hand or feet swelling, urinary tract infections, and blood in your urine (2).

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

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

How do other medical issues affect your kidneys?

Among the greatest risks for your kidneys are uncontrolled diseases and medical disorders, such as diabetes and hypertension (1). If you have – or are at risk for – diabetes, be sure to control your blood sugar levels to limit kidney damage. Similarly, if you currently have hypertension, controlling it will put less stress on your kidneys. 

For these diseases, it’s crucial that you have your kidney function tested at least once a year.

In addition, obesity and smoking have been identified as risk factors and can be managed by making lifestyle changes to reduce your risk.

Can diet help protect your kidneys?

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (3).

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

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (4). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower levels of eGFR.

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

The National Kidney Foundation recommends diets that are higher in fruit and vegetable content and lower in animal protein, including the Dietary Approaches to Stop Hypertension (DASH) diet and plant-based diets (5). 

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

What are our takeaways?

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

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

References:

(1) CDC.gov. (2) kidneyfund.org. (3) Clin J Am Soc Nephrol. 2013;8:371-381. (4) Clin J Am Soc Nephrol. 2010; 5:836-843. (5) kidney.org.

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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Even if you don’t use a salt shaker, you’re likely getting more sodium than the current guidelines. METRO photo
Eating whole foods can improve your odds of victory

By David Dunaief, M.D.

Dr. David Dunaief

We hear a lot about sodium and the importance of limiting your sodium intake. But what if you don’t have a health condition like hypertension? Should you still be concerned? The short answer is, “yes.” Most of us consume far too much sodium, as much at 3,400 mg per day, without even trying (1). Even if we don’t have hypertension, the impact of sodium on our health can be dramatic.

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

On the flip side, only about two percent of people get enough potassium from their diets (3). According to the National Institutes of Health, adequate intake of potassium is between 2600mg and 3400mg for adult women and men, respectively.

Why do we compare sodium and potassium intakes?

A high sodium-to-potassium ratio increases the risk of cardiovascular disease by 46 percent, according to a study that looked at more than 12,000 Americans over almost 15 years (4). In addition, both may have significant impacts on blood pressure and cardiovascular disease. To improve our overall health, we need to shift the sodium-to-potassium balance so that we consume more potassium and less sodium. And if you struggle with high blood pressure, this approach could help you win the battle.

Can sodium intake be too low?

Before we dive in too far, let’s address an “elephant in the room.” I’ve read several commentaries where experts warn that too-low sodium levels can be a problem. While this is true, it’s quite rare, unless you take medications or have a health condition that depletes sodium. We hide sodium everywhere, so even if you don’t use a salt shaker, you’re likely getting more sodium than the current guidelines.

Why lower your sodium consumption?

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

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

This was a meta-analysis that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. Salt reduction from 9-to-12 grams per day to 5-to-6 grams per day had a dramatic effect. The researchers believe that the more we reduce the salt intake, the greater the effect of reducing blood pressure. The authors recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

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

Is potassium consumption important?

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (7). When foods containing 3.5 to 4.7 grams of potassium were consumed, there was an impressive −7.16 mm Hg reduction in systolic blood pressure with high blood pressure patients. Anything more than this amount of potassium did not have any additional benefit. Increased potassium intake also reduced the risk of stroke by 24 percent. This effect was important.

The reduction in blood pressure was greater with increased potassium consumption than with sodium restriction, although this was not a head-to-head comparison. The good news is that potassium is easily attainable; it’s found in many whole foods and is richest in fruits, vegetables, beans and legumes.

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

References:

(1) Dietary Reference Intakes for Sodium and Potassium. Washington (DC): National Academies Press (US); 2019 Mar. (2) www.cdc.gov. (3) www.nih.gov. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) BMJ. 2013 Apr 3;346:f1325. (6) BMJ. 2013 Apr 3;346:f1326. (7) BMJ. 2013; 346:f1378.

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

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METRO photo
Diet and exercise together are the key to success

By David Dunaief, M.D.

Dr. David Dunaief

If you suffer from osteoarthritis, you know it can affect your quality of life and make it difficult to perform daily activities. Osteoarthritis (OA) most often affects the knees, hips and hands and can affect your mood, mobility, and sleep quality.

Common first-line medications that treat arthritis pain are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen. Unfortunately, these medications have side effects, especially with long-term use. Also, while they might relieve your immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression.

Fortunately, there are approaches you can use to ease your pain without reaching for medications. Some can even help slow the progression of your OA or even reverse your symptoms.

What role does weight play?

Weight management is a crucial component of any OA pain management strategy. In a study involving 112 obese patients, those who lost weight reported easing of knee symptoms (1). Even more exciting, the study authors observed disease modification, with a reduction in the loss of cartilage volume around the medial tibia. Those who gained weight saw the opposite effect.

The relationship was almost one-to-one; for every one percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the opposite occurred when participants gained weight. A reduction of tibial cartilage is often associated with the need for a knee replacement.

Does vitamin D help?

In a randomized controlled trial (RCT), vitamin D provided no OA symptom relief, nor any disease-modifying effects (2). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

In another study of 769 participants, ages 50-80, researchers found that low vitamin D levels – below 25 nmol/l led to increased OA knee pain over the five-year study period and hip pain over 2.4 years (3). The researchers postulate that supplementing vitamin D might reduce pain in those who are deficient, but that it will likely have no effect on others.

How does dairy factor into OA?

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

In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (4). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

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

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

On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (5).

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

Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I might not dissuade osteoarthritis patients from yogurt.

Does exercise help with OA pain?

Diet and exercise trumped the effects of diet or exercise alone in a well-designed study (7). In an 18-month study, patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation. This was compared to those who lost a lower percent of their body weight.

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

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

References:

(1) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (2) JAMA. 2013;309:155-162. (3) Ann. Rheum. Dis. 2014;73:697–703. (4) Arthritis Care Res online. 2014 April 6. (5) J Rheumatol. 2017 Jul;44(7):1066-1070. (6) Nutrients. 2021 Feb 4;13(2):506. (7) JAMA. 2013;310:1263-1273.

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

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By focusing on developing heart-healthy habits, we can improve the likelihood that we will be around for a long time. METRO photo
Modest dietary changes can have a big impact

By David Dunaief, M.D.

Dr. David Dunaief

With all of the attention on infectious disease prevention these past two years, many have lost sight of the risks of heart disease. Despite improvements in the numbers in recent years, heart disease in the U.S., making it the leading cause of death (1).

I have good news: heart disease is on the decline in the U.S. due to a number of factors, including better awareness, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. It still underpins one in four deaths, and it is preventable.

Manage your baseline risks

Significant risk factors for heart disease include high cholesterol, high blood pressure and smoking. In addition, diabetes, excess weight and excessive alcohol intake increase your risks. Unfortunately, both obesity and diabetes are on the rise. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2).

Inactivity and the standard American diet, rich in saturated fat and calories, also contribute to atherosclerosis, fatty streaks in the arteries, the underlying culprit in heart disease risk (3).

Another potential risk factor is a resting heart rate greater than 80 beats per minute (bpm). In one study, healthy men and women had 18 and 10 percent increased risks of dying from a heart attack, respectively, for every increase of 10 bpm over 80 (4). A normal resting heart rate is usually between 60 and 100 bpm. Thus, you don’t have to have a racing heart rate, just one that is high-normal. All of these risk factors can be overcome.

How does medication lower heart disease risk?

Cholesterol and blood pressure medications have been credited to some extent with reducing the risk of heart disease. Unfortunately, according to 2018 National Health and Nutrition Examination Survey (NHANES) data, only 43.7 percent of those with hypertension have it controlled (5). While the projected reasons are complex, a significant issue among those who are aware they have hypertension is a failure to consistently take prescribed medications, or medication nonadherence.

Statins also have played a key role in primary prevention. They lower lipid levels, including total cholesterol and LDL (“bad” cholesterol) but they also lower inflammation levels that contribute to the risk of cardiovascular disease. The JUPITER trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

The downside of statins is their side effects. Statins have been shown to increase the risk of diabetes in intensive dosing, when compared to moderate dosing (6).

Unfortunately, many on statins also suffer from myopathy (muscle pain). I have had a number of patients who have complained of muscle pain and cramps. Their goal is to reduce and ultimately discontinue their statins by following a lifestyle modification plan involving diet and exercise. Lifestyle modification is a powerful ally.

What lifestyle changes help minimize heart disease?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). 

The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required a modest change in diet.

The Nurses’ Health Study shows that these results are also seen in women, with lifestyle modification reducing the risk of sudden cardiac death (SCD). Many times, this is the first manifestation of heart disease in women. The authors looked at four parameters of lifestyle modification, including a Mediterranean-type diet, exercise, smoking and body mass index. The decrease in SCD that was dose-dependent, meaning the more factors incorporated, the greater the risk reduction. SCD risk was reduced up to 92 percent when all four parameters were followed (8). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

How can you monitor your heart disease risk?

To monitor your progress, cardiac biomarkers are telling, including inflammatory markers like C-reactive protein, blood pressure, cholesterol and body mass index. 

In a cohort study of high-risk participants and those with heart disease, patients implemented extensive lifestyle modifications: a plant-based, whole foods diet accompanied by exercise and stress management (9). The results showed an improvement in biomarkers, as well as in cognitive function and overall quality of life. Most exciting is that results occurred over a very short period to time — three months from the start of the trial. Many of my patients have experienced similar results.

Ideally, if a patient needs medications to treat risk factors for heart disease, it should be for the short term. For some patients, it may be appropriate to use medication and lifestyle changes together; for others, lifestyle modifications may be sufficient, as long as patient takes an active role.

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

References:

(1) cdc.gov/heartdisease/facts. (2) Diabetes Care. 2010 Feb; 33(2):442-449. (3) Lancet. 2004;364(9438):93. (4) J Epidemiol Community Health. 2010 Feb;64(2):175-181. (5) Hypertension. 2022;79:e1–e14. (6) JAMA. 2011;305(24):2556-2564. (7) J Nutr. March 1, 2005;135(3):556-561. (8) JAMA. 2011 Jul 6;306(1):62-69. (9) Am J Cardiol. 2011;108(4):498-507.

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

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For people who suffer from seasonal allergies, life is about to get really uncomfortable. METRO photo
Over the counter medications help some sufferers

By David Dunaief, M.D.

Dr. David Dunaief

This past weekend, we adjusted our clocks for Daylight Saving Time, the unofficial end of winter. Because it’s been warmer than usual this winter, I’ve noticed crocuses and daffodils are already sprouting and we’re just a few weeks out from full scale tree buds.

For people who suffer from seasonal allergic rhinitis, hay fever, seasonal allergies or whatever you would like to call it, life is about to get really uncomfortable. Just over 25 percent of U.S. adults were diagnosed with seasonal allergies in 2021, and 18.9 percent of children were diagnosed, according to the Centers for Disease Control and Prevention (1). The triggers for seasonal allergies are diverse. They include pollen from leafy trees and shrubs, grass and flowering plants, as well as weeds, with the majority from ragweed (mostly in the fall) and fungus (summer and fall) (2).

What triggers allergic reactions? 

A chain reaction occurs in seasonal allergy sufferers. When foreign substances such as allergens (pollen, in this case) interact with immunoglobulin E (IgE), antibodies that are part of our immune system, they cause mast cells in the body’s tissues to degrade and release inflammatory mediators. These include histamines, leukotrienes and eosinophils in those who are susceptible. In other words, it is an allergic inflammatory response.

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it emulates a cold, but without the virus. If symptoms last more than 10 days and are recurrent, then it is likely you have allergies, not a virus.

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

What medications help? 

The best way to treat allergy attacks is to prevent them, but this is can mean closing yourself out from the enjoyment of spring by literally closing the windows, using the air-conditioning, and using recycling vents in your car.

On the medication side, we have intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops, and leukotriene modifiers (second-line treatment only).

The guidelines for treating seasonal allergic rhinitis with medications suggest that intranasal corticosteroids (steroids) should be used when quality of life is affected. If there is itchiness and sneezing, then second-generation oral antihistamines may be appropriate (5). Two well-known inhaled steroids are Nasacort (triamcinolone) and Flonase (fluticasone propionate). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day and can have side effects, like headaches.

Oral antihistamines, on the other hand, can be taken on an as-needed basis. Second-generation antihistamines, such as loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra), have less sleepiness as a side effect than first-generation antihistamines, but don’t work for everyone.

Alternative treatments

 Butterbur (Petasites hybridus), an herb, has several small studies that indicate its efficacy in treating hay fever. In one randomized controlled trial (RCT) involving 131 patients, results showed that butterbur was as effective as cetirizine (Zyrtec) (6).

In another RCT, results showed that high doses of butterbur — 1 tablet given three times a day for two weeks — was significantly more effective than placebo (7). Researchers used butterbur Ze339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) in the trial.

A post-marketing follow-up study of 580 patients showed that, with butterbur Ze339, symptoms improved in 90 percent of patients with allergic rhinitis over a two-week period (8). Gastrointestinal upset occurred as the most common side effect in 3.8 percent of the population.

The caveats to the use of butterbur are several. First, the studies were short in duration. Second, the leaf extract used in these studies was free of pyrrolizidine alkaloids (PAs). This is very important, since PAs may not be safe. Third, the dose was well-measured, which may not be the case with over-the-counter extracts. Fourth, there are interactions with some prescription medications.

Treating allergies with diet?

While there are no significant studies on diet, there is one review of literature that suggests that a plant-based diet may reduce symptoms of allergies, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma. This is according to the International Study of Asthma and Allergies in Childhood study in 13- to 14-year-old teens (9). In my clinical practice, I have seen patients who suffer from seasonal allergies improve and even reverse the course of allergies over time with a vegetable-rich, plant-based diet, possibly due to its anti-inflammatory effect. Analogously, some physicians suggest that their patients have benefited from removing dairy from their diets.

While allergies can be miserable, there are a significant number of over-the-counter and prescription options to help reduce symptoms. Diet may play a role in the disease process by reducing inflammation, although there are no formal studies. There does seem to be promise with some herbs, like butterbur. However, alternative supplements and herbs lack large, randomized clinical trials with long durations. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

References:

(1) CDC.gov. (2) acaai.org/allergies/types/pollen-allergy. (3) J Allergy Clin Immunol. 2003 Dec;112(6):1021-31.. (4) J Allergy Clin Immunol. 2010 Jan;125(1):16-29.. (5) Otolaryngol Head Neck Surg. 2015 Feb;2:197-206. (6) BMJ 2002;324:144. (7) Arch Otolaryngol Head Neck Surg. 2004 Dec;130(12):1381-6. (8) Adv Ther. Mar-Apr 2006;23(2):373-84. (9) Eur Respir J. 2001;17(3):436-443.

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

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Micronutrient deficiency and obesity are intertwined

By David Dunaief, M.D.

Dr. David Dunaief

If you’re trying to lose weight, you’re probably closely watching your calorie intake. We’ve been trained for a lifetime to scrutinize calories and to exercise more willpower in avoiding high-calorie options.

However, the road to weight loss, or even weight maintenance, is complex. Many things influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

Awareness of a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or can encourage higher calorie purchases (1, 2).

The good news is that success is not solely about willpower. Instead, we need to change our diet composition.

In my clinical experience, increasing the quality of food has a tremendous impact. Foods that are the most micronutrient dense, such as plant-based foods, rather than those that are focused on macronutrient density, such as protein, carbohydrates and fats, tend to be the most satisfying. In a week to a few months of focusing on micronutrients, one of the first things patients notice is a significant reduction in cravings.

What is the impact of refined carbohydrates?

Generally, we know that refined carbohydrates don’t help. Looking deeper, a small, randomized control trial (RCT) showed refined carbohydrates actually may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown by MRI scans of trial subjects.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were blinded (unaware) as to which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number of calories consumed. Commonly found high-glycemic foods include items like white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates.

Do macronutrients matter?

We tend to focus on macronutrients — protein, carbohydrates and fats — when looking at diets. But are these the elements that have the greatest impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among study groups, nor was there much success in helping obese patients reduce their weight (4, 5). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Again, focusing primarily on macronutrient levels and calorie counts did very little to improve results.

What’s the relationship between micronutrients and weight?

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be micronutrient-deficient (6). Micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements doesn’t solve the problem; generally, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation, by adding variety to your diet. Please ask your doctor.

How do cortisol levels affect health?

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

Cortisol raises blood-levels of glucose and is involved in promoting visceral or intra-abdominal fat. This type of fat can coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality. This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about willpower or calorie-counting. While calorie intake has a role, the nutrient density of the food may be more important to your success and may play a significant role in reducing cravings, ultimately helping to manage weight in the long run.

References:

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) Am J Clin Nutr Online 2013;Jun 26. (4) N Engl J Med 2009 Feb 26;360:859. (5) N Engl J Med 2009 Feb 26;360:923. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

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

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METRO photo
              The microbiome may have an impact on susceptibility to autoimmune diseases

By David Dunaief, M.D.

Dr. David Dunaief

Every human carries in its body a microbiome, consisting of bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, and much of it is still only loosely understood. What we do know, however, is that these trillions of microorganisms have key roles in our healthy functioning.

The microbiome is found throughout our bodies, including the skin, the eyes and the gut. Here, we’re going to focus on the gut, where the majority of our microbiome resides. The microbiome has been getting a lot of attention of late, because of its possible role in preventing and promoting diseases. Among these are obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

The Human Microbiome Project

Like the Human Genome Project, which mapped our genes, the Human Microbiome Project, funded by the National Institutes of Health from 2007 to 2016, sought to map and sequence the composition and diversity of these gut organisms and to prompt future research. Already, there have been some enlightening preliminary studies.

What affects the microbiome?

Drugs, such as antibiotics, can wipe out microbial diversity, at least in the short term. Also, lifestyle modifications, such as diet, can have a positive or negative impact. Microbiome diversity also may be significantly different in distinct geographic locations throughout the world.

The microbiome and obesity

Many obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1).

For a long time, the paradigm for weight loss had been to cut calories. However, extreme low-calorie diets were not having a long-term impact. It turns out that our guts, dominated by bacteria, may play important roles in obesity and weight loss, determining whether we gain or lose weight.

The results from a study involving human twins and mice are fascinating (2). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. Interestingly, they only lost weight when on a good diet. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not clear yet which bacteria may be contributing these effects.

This suggests that gut bacteria diversity may be a crucial piece of the weight-loss puzzle.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant morning stiffness, joint soreness and joint breakdown. What if gut bacteria influenced RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (3). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Can you counteract antibiotics’ negative effects?

Many have gastrointestinal upset while taking antibiotics, because antibiotics don’t differentiate between good and bad bacteria when they go to work. 

One way to counteract these negative effects is to take a probiotic during and after your course of antibiotics. I recommend Renew Life’s 30-50 billion units once a day, two hours after an antibiotic dose and continuing once a day for 14 days after you have finished your prescription. If you really want to ratchet up the protection, you can take one dose of probiotics two hours after every antibiotic dose.

Although nobody can say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, seem to be important to the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. The research is continuing, but we’ve learned a lot already that may help us tackle obesity and autoimmune disorders.

References:

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) Science. 2013;341:1241214. (3) PLoS One. 2012;7:e36095. (4) Nutrients. 2019 Dec;11(12):2862.

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

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