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Legume consumption plays an important role

By David Dunaief, M.D.

Dr. David Dunaief

Coronary artery disease is the most common type of heart disease, which can cause heart attacks. How common is it? According to the Centers for Disease Control and Prevention, about 6.7 percent of U.S. adults over the age of 19 have coronary artery disease (CAD) (1). There are 805,000 heart attacks in the U.S. annually, and 200,000 of these occur in those who’ve already had a first heart attack.

Among the biggest contributors to heart disease risk are high blood pressure, high cholesterol, and smoking. In addition, if you have diabetes or are overweight or obese, your risk increases significantly. Lifestyle factors also contribute to your risk: poor diet, lack of physical activity and high alcohol consumption are among the most significant contributors.

This is where we can have a tremendous impact and significantly reduce the occurrence of CAD. Evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Changes that garner a big bang for your buck include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Chocolate’s benefits

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

I usually recommend that patients have one to two squares — about one-fifth to two-fifths of an ounce — of high-cocoa-content dark chocolate daily. Aim for chocolate labeled with 80 percent cocoa content.

Alternatively, you can get the benefits without the fat and sugar by adding unsweetened, non-Dutched cocoa powder to a fruit and vegetable smoothie.

Who says prevention has to be painful?

Increase dietary fiber

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

According to a 2021 analysis of National Health and Nutrition Examination Survey (NHANES) data from 2013 to 2018, only 5 percent of men and 9 percent of women get the recommended daily amount of fiber (4).

The average American consumes about 16 grams per day of fiber (5).

So, how much is “enough”? The Academy of Nutrition and Dietetics recommends 14 grams of fiber for each 1,000 calories consumed, or roughly 25 grams for women and 38 grams for men (6).

We can significantly reduce our risk of heart disease if we increase our consumption of fiber to reach the recommended levels. Good sources of fiber are fruits and vegetables with the edible skin or peel, beans and lentils, and whole grains.

Consume more legumes

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, legumes reduced the risk of coronary heart disease by a significant 22 percent (7). Those who consumed four or more servings per week saw this effect when compared to those who consumed less than one serving per week. The legumes used in this study included beans, peas and peanuts. There were over 9,500 men and women involved, and the study spanned 19 years of follow-up.

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

Focus on healthy nuts

In a study with over 45,000 men, there were significant reductions in CAD with omega-3 polyunsaturated fatty acids (PUFAs). Both plant-based and seafood-based omega-3s showed these effects (8). Good sources of omega-3s from plant-based sources include nuts, such as walnuts, and ground flaxseed.

Your ultimate goal should be to become “heart attack proof,” a term used by Dr. Sanjay Gupta and reinforced by Dr. Dean Ornish. While even modest dietary changes can significantly reduce your risk, the more significant the lifestyle changes you make, the closer you will come to achieving this goal.

References: 

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) nutrition.org (5) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (6) eatright.org. (7) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (8) Circulation. 2005 Jan 18;111(2):157-164.

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

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High-fiber salads can help fight hemorrhoid pain. METRO photo
Simple methods to prevent constipation can help

By David Dunaief, M.D.

Dr. David Dunaief

For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms — and often say we “have hemorrhoids,” when we really mean our hemorrhoids are causing us pain.

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and childbirth. When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually 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.

When they are outside

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Because they can be self-treated, they generally do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet 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 see your physician to make sure it is not due to a malignancy or other cause, such as inflammatory bowel disease.

When they are inside

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they 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 falled out of place, due to weakening of the muscles and ligaments in the colon. This prolapse 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, the daily incidence of bleeding decreased dramatically (3).

When issues are more severe

There are several minimally invasive options, 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 place 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.

Preventing hemorrhoid problems

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing 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. It helps to soften the stool and prevent constipation. Exercise also helps to prevent constipation. It is important not to hold in a bowel movement; go when the urge is there or else the stool can become hard, causing straining, constipation and more time on the toilet. 

Increasing your fiber intake

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining. Thus, you should try to increase the amount of fiber in your diet before adding supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes 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. 

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.

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.

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Pixabay photo
The list of fiber’s health benefits is growing

By David Dunaief, M.D.

Dr. David Dunaief

According to the most recent USDA survey data, Americans are woefully deficient in fiber, consuming between 10 and 15 grams per day. Breaking it down further into fiber subgroups, consumption levels for legumes and dark green vegetables are the lowest in comparison to suggested levels (1). This has pretty significant implications for our overall health and weight.

Still, many people worry about getting enough protein. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases to the degree that studies illustrate with fiber.

So, how much fiber 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.

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber-rich.

All fiber is not equal

Does the type of fiber 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. Some are more effective in preventing or treating certain diseases. 

Take, for instance, one irritable bowel syndrome (IBS) study (2). It was a meta-analysis of 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Reducing disease risk and mortality

Fiber has very 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 (3). Over a nine-year period, those who ate the most fiber, in the highest quintile group, were 22 percent less likely to die than those in 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 (4).

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 (5). 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 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 (6). 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.

Where is the fiber?

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease-dependent. However, 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) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (3) Arch Intern Med. 2011;171(12):1061-1068. (4) Lancet. 2019 Feb 2;393(10170):434-445. (5) Amer J Epidemiology 2008;167(5):570-578. (6) 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.

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Eating a high-fiber breakfast cereal is a great way to start. METRO photo
Increasing fiber intake may help modulate the immune system

By David Dunaief, M.D.

Dr. David Dunaief

When the immune system attacks the body’s own organs, cells and tissues and causes chronic inflammation, we classify it as an autoimmune disease. However, this umbrella term refers to more than 80 different diseases (1). Some are familiar names, like type 1 diabetes, lupus, rheumatoid arthritis (RA), psoriasis, multiple sclerosis, and inflammatory bowel disease. Others, like Lambert-Eaton myasthenic syndrome and Cogan syndrome, are less well-known.

Chronic inflammation is the main consequence of immune system dysfunction, and it is the underlying theme tying these diseases together. Unfortunately, autoimmune diseases tend to cluster (2). Once you have one, you are at high risk for acquiring others. Autoimmune diseases disproportionately affect women, although men do also get them.

Drug treatments

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

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

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

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

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

Nutrition and inflammation

Raising the level of beta-cryptoxanthin, a carotenoid bioactive food component, by a modest amount has a substantial impact in preventing RA. Several studies have also tested dietary interventions in RA treatment (5). Included were fasting followed by a vegetarian diet; a vegan diet; and a Mediterranean diet, among others. All mentioned here showed decreases in inflammatory markers, including CRP, and improvements in joint pain and other quality of life concerns.

Fish oil supplementation

Fish oil helps your immune system by reducing inflammation and improving your blood chemistry, affecting as many as 1,040 genes (6). In a randomized clinical study, 1.8 grams of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation had anti-inflammatory effects, suppressing cell signals and transcription factors (proteins involved with gene expression) that are pro-inflammatory, such as NFkB.

In RA patients, fish oil helps suppress cartilage degradative enzymes, while also having an anti-inflammatory effect (7). When treating patients with autoimmune disease, I typically suggest about 2 grams of EPA plus DHA to help regulate their immune systems. Don’t take these high doses of fish oil without consulting your doctor, since fish oil may have blood-thinning effects.

Probiotic supplements

The gut contains approximately 70 percent of your immune system. Probiotics, by populating the gut with live beneficial microorganisms, have immune-modulating effects that decrease inflammation and thus are appropriate for autoimmune diseases. Lactobacillus salvirus and Bifidobacterium longum infantis are two strains that were shown to have positive effects (8, 9).

In a study with Crohn’s disease patients, L. casei and L. bulgaricus reduced the inflammatory factor TNF-alpha (10). To provide balance, I recommend probiotics with Lactobacillus to my patients, especially with autoimmune diseases that affect the intestines, like Crohn’s and ulcerative colitis.

Fiber intake

Fiber has been shown to modulate inflammation by reducing biomarkers, such as CRP. In two separate clinical trials, fiber either reduced or prevented high CRP in patients. In one, a randomized clinical trial, 30 grams, or about 1 ounce, of fiber daily from either dietary sources or supplements reduced CRP significantly compared to placebo (11). In the second trial, which was observational, participants who consumed the highest amount of dietary fiber (greater than 19.5 grams) had reductions in a vast number of inflammatory factors, including CRP, interleukin-1 (IL-1), interleukin-6 (IL-6) and TNF-alpha (12).

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

References:

(1) niaid.nih.gov. (2) J Autoimmun. 2007;29(1):1. (3) epocrates.com. (4) J Rheumatol 1999;26(8):1705-1714. (5) Front Nutr. 2017; 4: 52. (6) Am J Clin Nutr. 2009 Aug;90(2):415-424. (7) Drugs. 2003;63(9):845-853. (8) Gut. 2003 Jul;52(7):975-980. (9) Antonie Van Leeuwenhoek 1999 Jul-Nov;76(1-4):279-292. (10) Gut. 2002;51(5):659. (11) Arch Intern Med. 2007;167(5):502-506. (12) Nutr Metab (Lond). 2010 May 13;7:42.

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

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Eating a diet rich in high fiber can help relieve the symptoms of hemorrhoids. Pixabay photo
Hydration, fiber and exercise help reduce problems

By David Dunaief, M.D.

Dr. David Dunaief

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and child birth. For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms – and often say we “have hemorrhoids,” when we really mean our hemorrhoids are causing us pain.

When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually bleed, especially during a bowel movement, which may scare us. 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. 

External hemorrhoids

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Thus, they can be self-treated and do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet and supplementation (1). However, sometimes there is thrombosis (clotting) of external hemorrhoids, in which case they may become more painful, requiring medical treatment.

Internal hemorrhoids

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they are usually above the point of sensation in the colon, called the dentate line. If the hemorrhoids prolapse below this, there may be pain and discomfort, as well. Prolapse is when hemorrhoids fall out of place, due to weakening of the muscles and ligaments in the colon. 

The first step for treating internal hemorrhoids is to 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, the daily incidence of bleeding was reduced dramatically (3).

There are several minimally invasive options, including anal banding, sclerotherapy and coagulation. The most effective of these is anal banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where two rubber bands are place at the neck of each hemorrhoid. 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.

Preventing hemorrhoid problems

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing 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.

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

Thus, you should try to increase the amount of fiber in your diet, before adding supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes 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. 

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 40g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65g per 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.

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

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

The message throughout this article is that Americans need to get more fiber, which is beneficial for inflamed hemorrhoid prevention and treatment.

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. 

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Stock photo
Fiber has very powerful effects on our overall health

By David Dunaief

Dr. David Dunaief

Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily.

Still, many people worry about getting enough protein, when they really should be concerned about getting enough fiber. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases to the degree that studies illustrate with fiber. 

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber-rich.

All fiber is not equal

Does the type of fiber 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. Some are more effective in preventing or treating certain diseases. Take, for instance, a 2004 irritable bowel syndrome (IBS) study (1). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Reducing disease risk and mortality

Fiber has very 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, in the highest quintile group, were 22 percent less likely to die than those in 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. 

Along the same lines of the respiratory findings, we 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 (3). 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 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 (4). 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 also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

Where do we find fiber?

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease-dependent. However, if you are trying to prevent chronic diseases in general, I would recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased 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) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (2) Arch Intern Med. 2011;171(12):1061-1068. (3) Amer J Epidemiology 2008;167(5):570-578. (4) 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. 

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

By David Dunaief, M.D.

Dr. David Dunaief

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

These make up what we call the microbiome. It includes bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, spanning from parasitic to commensalistic (one benefits and the other is not affected) to mutualistic (both benefit). While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where the majority of the microbiome resides.

Why do we care about the gut microbiome? 

The short answer is it may have a role in diseases — preventing and promoting them. These include obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis. Like the Human Genome Project, which mapped our genes, there is a Human Microbiome Project, launched by the National Institutes of Health in 2007, to map out the composition and diversity of these gut organisms. We are still in the early stages of understanding this vast universe of microbes, yet there have been some preliminary studies.

What affects the microbiome? 

Drugs, such as antibiotics, can wipe out the diversity in the microbes, at least in the short term. Also, lifestyle modifications, such as diet, can have an impact. Microbiome diversity also may be significantly different in distinct geographic locations throughout the world. Let’s look at the evidence.

Using twins to study obesity

Obesity can be one of the most frustrating disorders; most obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (1). 

I know this will not come as a surprise, but we are a nation with a weight problem; about 70% of Americans are overweight or obese (2) (3). For the longest time, the paradigm for weight loss had been that if you ate fewer calories, you would lose weight. However, extreme low-caloric diets did not seem to have a long-term impact. It turns out that our guts, dominated by bacteria, may play important roles in obesity and weight loss, determining whether we gain or lose weight. Let’s look at the data on obesity.

The results from a study involving human twins and mice are fascinating (4). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

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

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. But they only lost weight when on a good diet; there was no impact if the diet was not low in fat. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not clear yet which bacteria may be contributing these effects.

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

Do gut bacteria influence rheumatoid arthritis development?

Rheumatoid arthritis (RA) is an autoimmune disease that can be disabling, with patients typically suffering from significant morning stiffness, joint soreness and joint breakdown. What if gut bacteria influenced RA risk? In a study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (5). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacteria and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the bacteria in the RA-resistant mice are known for their anti-inflammatory effects.

Although nobody can say what the ideal gut bacteria should consist of, and the research is still evolving when it comes to the microbiome, there are potential ways of influencing this milieu, especially in our gut. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, seem to be important to the composition and diversity of gut bacteria (6). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables and plant fiber. The research is continuing, but we’ve learned a lot already that may help us tackle obesity, inflammatory bowel syndrome and autoimmune disorders.

References:

(1) “The Evolution of Obesity”; Johns Hopkins University Press; 2009. (2) cdc.gov (3) nih.gov (4) Science. 2013;341:1241214. (5) PLoS One. 2012;7:e36095. (6) Nutrients. 2019 Dec;11(12):2862.

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

Drug treatments

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

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

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

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

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

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

Nutrition and inflammation

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

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

Fish oil

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

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

Probiotic supplements

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

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

Fiber

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

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

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

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

References:

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

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

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All fruits, vegetables, whole grains, nuts, seeds and beans contain some fiber. Stock photo
Fiber has powerful effects on disease prevention and reversal

By David Dunaief, M.D.

Many people worry about getting enough protein, when they really should be concerned about getting enough fiber. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases in the way that studies illustrate with fiber. 

Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily. 

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber rich.

Fiber has very 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 (1). Over a nine-year period, those who ate the most fiber, in the highest quintile group, 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. 

Along the same lines of the respiratory findings, we 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 (2). 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 not as great.

Does the type of fiber 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. Some are more effective in preventing or treating certain diseases. Take, for instance, a February 2004 irritable bowel syndrome (IBS) study (3). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

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 (4). 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 also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease dependent. However, if you are trying to prevent chronic diseases in general, I would recommend getting fiber from a wide array of sources. 

Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased 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) Arch Intern Med. 2011;171(12):1061-1068. (2) Amer J Epidemiology 2008;167(5):570-578. (3) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (4) Amer J Clinical Nutrition 2009;90(3):664–671. 

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

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One can maintain regular bowel movement and lessen the risk of inflamed hemorrhoids by including more fiber in his or her diet, about 30 g per day. Stock photo
Most Americans don’t get enough fiber

By David Dunaief, M.D.

Dr. David Dunaief

Many of us have suffered at one time or another from inflamed hemorrhoids. They affect men and women equally, though women have a higher propensity during pregnancy and child birth. For some reason, there’s a social stigma associated with hemorrhoids, although we all have them. They’re vascular structures that aid in stool control. When they become irritated and inflamed, we have symptoms — and often say we “have hemorrhoids” — when we really mean our hemorrhoids are causing us pain. 

When they’re irritated, hemorrhoids may alternate between itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They usually bleed, especially during a bowel movement, which may scare most of us. Fortunately, hemorrhoids are not a harbinger of more serious disease. 

Treating external hemorrhoids

Fortunately, external hemorrhoids tend to be mild. Most of the time, they are treated with analgesic creams or suppositories that contain hydrocortisone, such as Preparation H, or with a sitz bath, all of which help relieve the pain. Thus, they can be self-treated and do not require an appointment with a physician. The most effective way to reduce bleeding and pain is to increase fiber through diet and supplementation (1). However, sometimes there is thrombosis (clotting) of external hemorrhoids, in which case they may become more painful, requiring medical treatment.

Treating internal hemorrhoids

Internal hemorrhoids can be a bit more complicated. The primary symptom is bleeding with bowel movement, not pain, since they are usually above the point of sensation in the colon, called the dentate line. If the hemorrhoids prolapse below this, there may be pain and discomfort, as well. Prolapse is when hemorrhoids fall out of place, due to weakening of the muscles and ligaments in the colon. 

The first step for treating internal hemorrhoids is to 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, the daily incidence of bleeding was reduced dramatically (3).

There are several minimally invasive options, including anal banding, sclerotherapy and coagulation. The most effective of these is anal banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where two rubber bands are place at the neck of each hemorrhoid. 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 to prevent hemorrhoids

First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing 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.

Eating more fiber helps to create bulk for your bowel movements, avoiding constipation, diarrhea and undue straining. Thus, you should try to increase the amount of fiber in your diet, before adding supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes have significant amounts of fiber. Grains, beans and nuts have among the highest levels of fiber. For instance, one cup of black beans has 12 g of fiber. 

Americans, on average, consume 16 g per day of fiber (5). For the average female or male between ages 31 and 50, the USDA recommends 25 and 30 g per day, respectively (6). I would recommend at least 40 g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65 g per 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.

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

If you have rectal bleeding and either have a high risk for colorectal cancer or are over the age of 50, you should see your physician to make sure it is not due to a malignancy or other cause, such as inflammatory bowel disease. The message throughout this article is that Americans need to get more fiber, which is beneficial for inflamed hemorrhoid prevention and treatment.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-456. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-1507. (4) Dis Colon Rectum 2004 Aug;47(8):1364-1370. (5) emedicine.com 2010. (6) health.gov. 

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

We invite you to check out our new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.

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