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Watching four or more hours of television has shown to cause an increased risk of cardiovascular disease mortality of 80 percent. METRO photo
Expanded viewing habits have effects on your physical and mental health

By David Dunaief, M.D.

Dr. David Dunaief

Comcast, one of America’s largest cable and internet providers, reported in May that Americans were watching an additional 8-plus hours of programming a week, whether on a television, computer or a portable device since the pandemic’s beginning (1). For our purposes, we’ll call this TV, because most is consumed while sitting, although the average watching modality has shifted considerably.

What impact does all this watching have on our lives? It may be hazardous to your health. I know this seems obvious, but bear with me. The extent of the effect is surprising. According to 2013 Netflix research, binge-watching, or watching more two or more episodes of a single program in a row, is perceived as providing a refuge from our busy lives.

This also has an addictive effect, prompting dopamine surges as we watch. Interestingly, it also can lead to post-binge depression when a show ends and to isolation and lower social interaction while viewing (2). Of course, while socially isolating, binge watching can help kill hours, but the negative effects are still relevant.

TV’s detrimental effect extends beyond the psychological, potentially increasing the risk of heart attacks, diabetes, depression, obesity and even decreasing or stunting longevity. My mother was right when she discouraged us from watching television, but I don’t think even she knew the extent of its impact.

Cardiovascular events including heart attacks

There was a very interesting observational study published in the New England Journal of Medicine that showed watching sporting events increases the risk of heart attacks and other cardiovascular events, such as arrhythmia (irregular heartbeat) and unstable angina (severe chest pain ultimately due to lack of oxygen). The researchers followed Germans who watched the FIFA (soccer) World Cup playoffs in 1996.

How much did watching increase the risk of cardiovascular events? This depended on what round of the playoffs and how close a game it was. The later the round and the closer the game, the greater the risk of cardiovascular events. Knockout games, which were single elimination, seemed to have the greatest impact on cardiovascular risk.

When Germany was knocked out in the semi-finals, the finals between France and Italy did not have any cardiovascular effect.

Overall, men experienced a greater than three-fold increase in risk, while women experienced an increased risk that was slightly below two-fold. According to the authors, it was not the outcome of the game that mattered most, but the intensity. The study population involved 4,279 German residents in and around the Munich area (3).

Another study found that, compared to fewer than two hours a day, those who watched four or more hours experienced an increased risk of cardiovascular disease mortality of 80 percent. I know this sounds like a lot of TV, but the average daily American viewing time is significantly over this. This study, called the Australian Diabetes, Obesity, and Lifestyle study (AusDiab) was observational looking at 8800 adults over a six-year period (4).

Impact on Life Expectancy

The adage that life tends to pass you by when you watch TV has a literal component. An observational study found that TV may reduce the life expectancy of viewers. In the study, those who watched at least six hours per day during their lifetime had a decrease in longevity of 4.8 years. However, this is not the whole story. What is even more telling is that after the age of 25, for every hour of TV, one might expect to potentially lose 21.8 minutes of life expectancy (5). According to the authors, these results rival those for obesity and sedentary lifestyles.

Diabetes and Obesity Risk

In the Nurses’ Health Study, for every two hours of television viewing on a daily basis there were increased risks of type 2 diabetes and obesity of 23 percent and 14 percent, respectively (6). The results show that sitting at work for two hours at time increased the risk of diabetes and obesity by only five percent and seven percent respectively, much less of an effect than TV-watching. The authors surmise that we can reduce the incidence of diabetes and obesity by 43 percent and 30 percent by cutting our TV time by 10 hours a week.

Modestly reducing the amount of television is a simple lifestyle modification that can have a tremendous impact on longevity, quality of life and prevention of the top chronic disease. So, step away from your television, tablet or computer and take a walk outside, do some calisthenics, or even take up a new hobby that doesn’t involve sitting on the couch. Your body and your psyche will thank you.

References:

(1) corporate.comcast.com (2) nbcnews.com/better/health/what-happens-your-brain-when-you-binge-watch-tv-series-ncna816991. (3) N Engl J Med 2008; 358:475-483. (4) Circulation. 2010 Jan 26;121(3):384-91. (5) Br J Sports Med doi:10.1136/bjsm.2011.085662. (6) JAMA. 2003 Apr 9;289(14):1785-91.

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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Doctor Says People Can Be Impacted by Califorinia Fires as Far as Long Island

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Scenes of the ash and smog from wildfires in the West Coast not only trigger sympathy for those with friends and family living in a paradise under siege, but also are a cause for concern for doctors who specialize in the lungs.

Dr. Norman Edelman. Photo from SBU

While doctors don’t know how far and wide the effects of these fires might be for those who are already struggling with their breathing, such as people with asthma, chronic obstructive pulmonary disease or chronic bronchitis, physicians said the effect could spread well beyond the areas battling these blazes.

The danger is “not just at the site of the fire,” said Dr. Norman Edelman, a professor of medicine at Stony Brook University and a core member of the program in public health at Stony Brook. “I’m sure [the effect of the fire] is pretty wide.”

Indeed, at some point down the road, the small and large particles that are aerosolized during the fire could reach as far away as Long Island.

“We know quite firmly that air pollution from coal burning generator plants [in the Midwest] emits pollution that makes its way all the way to the East Coast,” Edelman said.

The current use of masks may offer some protection for residents on the West Coast.

Particulates, which are aerosolized particles that can get in people’s lungs and affect their breathing, come in various sizes. The larger ones tend to get lodged in people’s noses, throat and eyes and can cause coughing, hacking, and watery eyes. An ordinary mask can filter some of those out, although masks are not completely effective for these bigger particles.

The smaller ones are more dangerous, Edelman said. They can get further into the lungs and can exacerbate asthma, chronic bronchitis and emphysema. They can even contribute to increased incidence of heart attacks.

“Nobody really knows” why these smaller particles contribute to heart attacks, Edelman said. Anecdotal evidence suggests that a reduction in pollution improves the health of a population.

When New York banned smoking in all public places, the level of heart attacks dropped by 15 to 20 percent.

“This level of pollution is nothing like what we’re seeing in the area of the wildfires,” Edelman said.

Additionally, lower pollution can improve the health of people with lung problems.

At the Summer Olympics in Atlanta in 1996, officials put in alternate day driving restrictions, which allowed people to drive every other day. By cutting down the pollution from traffic, doctors noticed a 25% reduction in admission to the emergency room for asthma.

If he were a doctor on the West Coast, Edelman said he would make sure his patients had all their medications renewed and available. He would also check in with his patients to make sure they had emergency instructions in case they need to boost the amount of any pharmacological agents.

The effect of the pollutants on people with asthma or other lung issues can be more severe if they are already dealing with an inflamed airway.

“The effects of various irritants are probably synergistic,” Edelman said. “If this is your allergy season, you become much more susceptible to the inflammatory effects of air pollution.”

COVID and the Lungs

As for the pandemic, Edelman said he didn’t come to the emergency room to work at the Intensive Care Unit during the pandemic.

His colleagues did, however, ask him to take care of patients who didn’t have to come in by telehealth. He’s continued to see many patients over the last three or four months.

One surprise from the data he’s seen related to the pandemic is that asthma does not seem to exacerbate the effects of COVID-19.

People with asthma “are not dying with COVID at any greater rate than the general population,” Edelman said.

He hasn’t yet seen the data for people with chronic bronchitis or COPD.

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The Centers for Disease Control and Prevention has recommended that people wear cloth face coverings in public settings where social distancing measures are difficult to maintain. Even as the world begins to unpause, wearing masks seems likely to continue.

Masks are designed not to prevent the wearer from getting ill, but to protect other people from getting the virus. Masks protect others from your germs when you cough or sneeze. They’re also an effective way to help people to avoid touching their faces.

Masks are exposed to the elements and germs each time they are worn, meaning they will require cleaning. Even though Harvard Health suggests COVID-19 may live more readily on hard surfaces than fabric, the CDC urges people to give cloth face masks the same level of care as regular laundry. Masks should be washed and dried often. The CDC offers these tips on how to clean most cloth and fabric masks.

• Fabric face masks should be washed depending on the frequency of use. More frequent use necessitates more frequent washing.

• A washing machine should be adequate for properly washing a face covering. Choose a warm setting for water temperature. Place masks in the dryer afterward.

• More delicate, hand-sewn masks may be washed by hand, suggests The Good Housekeeping Institute Cleaning Lab. Lather masks with soap and scrub them for at least 20 seconds with warm or hot water before placing in the dryer.

• For additional sanitation, iron masks on the cotton or linen setting for a few minutes to kill remaining germs.

• If masks are fortified with a filter, such as a coffee or HVAC filter, keep in mind that these filters are designed for single use. Paper filters should be replaced after each use. HVAC filters are washable, but manufacturers warn that their effectiveness decreases with each wash. Medium weight nonwoven interface used as filter material is typically washable.

Various health agencies do not condone using steam or microwaves to clean cloth face masks, as these sanitizing techniques are not as effective as regular laundering. Also, never microwave non-fabric dust or N95 respirator masks if you are using them. They can catch fire or be rendered useless.

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Exercise plays a crucial role in lowering blood pressure. Stock photo
Nighttime pressure readings may better predict cardiovascular events

By David Dunaief, M.D.

Dr. David Dunaief

Roughly 45 percent of adults in the U.S. have hypertension, or high blood pressure. That’s almost one in two adults, or 108 million people, of which 82 million do not have their hypertension con-trolled. If that isn’t scary enough, the Centers for Disease Control and Prevention (CDC) reports that almost a half-million people died in the U.S. in 2017 from complications of hypertension in 2017 (1).

Speaking of scary, the probability of complications, such as cardiovascular events and mortality, may have their highest incidence during nighttime sleeping hours.

Unfortunately, as adults, it does not matter what age or what sex you are; we are all at increased risk of complications from high blood pressure. Fortunately, hypertension is highly modifiable in terms of reducing the risk of cardiovascular disease and mortality (2). At least some of the risk factors are probably familiar to you. These include being significantly overweight or obese, smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits. These include lifestyle modifications with diet, exercise and potentially supplements.

Risk factors matter, but not equally

In an observational study involving 2,763 participants, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (4). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²), which put participants at 1.87 times increased risk. This surprisingly, albeit slightly, trumped cigarette smoking at 1.83 times increased risk.

The moral is that a freewheeling lifestyle can have a detrimental impact on blood pressure and cause at least stage 1 hypertension.

Hypertension complications are felt across gender, age and race

While the data show that more men than women have hypertension, 47 percent vs. 43 percent, and the prevalence of high blood pressure varies by race, the consequences of hypertension are felt across the spectrum of age, gender and race (1).

One of the most feared complications of hypertension is cardiovascular disease. In a study, isolated systolic (top number) hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (5). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, it was very large and had a 31-year duration.

Nighttime concerns

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (6).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration. Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (7). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

Previously, a study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Eat your berries

Diet plays a role in controlling high blood pressure. In a study, blueberry powder (22 grams) in a daily equivalent to one cup of fresh blueberries reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (9).

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase a substance called nitric oxide, which helps blood vessels relax, reducing blood pressure.

In conclusion, nighttime can be scary for high blood pressure and its cardiovascular complications, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References:

(1) CDC.gov. (2) Diabetes Care 2011;34 Suppl 2:S308-312. (3) uptodate.com. (4) BMC Fam Pract 2015;16(26). (5) J Am Coll Cardiol 2015;65(4):327-335. (6) J Am Coll Cardiol 2015;65(4):327-335. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377. (10) JAMA Pediatr online April 27, 2015.

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

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Owners of Huner’s Fitness Advantage in Port Jefferson said they believe they should be considered essential for the work they do helping people remain active and healthy. Photo from Huner’s Fitness Advantage website

After doing heavy lifting to ensure customer and employee safety, gyms can begin to reopen soon.

Suffolk County Executive Steve Bellone (D) announced a gradual gym reopening starting this Monday, Aug. 24. This comes after earlier this week Gov. Andrew Cuomo (D) said gyms can start to reopen once they receive guidance from local government.

Commercial gyms, such as Planet Fitness, LA Fitness, Retro Fitness and those that require a membership fee, along with indoor classes can restart next week.

Each fitness center will have to pass a county health inspection to make sure the gyms have sufficient procedures to protect staff and customers while following state guidelines established by Cuomo.

Hotel, office, higher education and residential gyms can reopen starting the following week, on Aug. 31.

On Thursday, Aug. 20, the county will host a virtual meeting with facility owners to review guidance, answer questions and provide any clarifications.

“With our infection rate holding steady at or below 1 percent and a robust testing system in place, we are confident we can reopen gyms in a way that is both safe and responsible,” Bellone said in a statement. “I want to remind our residents and gym owners that we are still in the midst of a pandemic.”

Bellone encouraged those attending gyms to wear a mask and follow all safety procedures.

Communal showers, whirlpools, saunas and steam rooms and water fountains and self-serve bars and samples must remain closed. According to the governor’s web site, individual showers and stalls can remain open as long as they are cleaned between use.

Classes are restricted to the most restrictive guidelines, which could either be six feet of distance in all directions from a participant, a limit of 33 percent capacity and no more than 50 people.

Gym owners also must provide sanitizing stations, acceptable face coverings, which exclude bandanas, buffs and gaiters and the limitation of physical contact activities including boxing and martial arts.

During each inspection, businesses will receive a gallon of NYS Clean hand sanitizer.

According to Cuomo, local health departments are required to inspect gyms prior to reopening or within two weeks of reopening, to ensure strict adherence to the state Department of Health guidance.

Indeed, the Suffolk County Department of Health Services will begin inspections on Monday, Aug. 24 for commercial and traditional gyms.

“New Yorkers must closely adhere to the guidelines and local health departments are required to strictly enforce them to help ensure gyms and fitness center reopen safely and protect the public health,” Cuomo said in a statement.

The Suffolk County Department of Economic Development and Planning will work with the Suffolk County Department of Labor, Licensing and Consumer Affairs and the Suffolk County Department of Health Services to create an online database of gyms and fitness centers within the county.

Before an inspection, gym owners will need to complete the affirmation for each location, which owners can find at the New York Forward website forward.ny.gov, that they reviewed and understood the state guidelines and will implement these protocols.

After owners attest to their safety plans, the county will schedule inspections. Suffolk will send out an email with the date and approximate time for an inspection.

Gym owners need to post a written safety plan describing the ways they are protecting employees and gym members from COVID-19.

Cuomo also requires that gyms use a MERV-13 or greater air-handling system. If the gym can’t operate at that level, the owners need to have a heating, ventilation and air conditioning professional document their inability to use such a system and adopt additional ventilation and mitigation protocols from the American Society of Heating, Refrigerating and Air-Conditioning Engineers and the U.S. Centers for Disease Control and Prevention.

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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Dr. Adam Gonzalez Photo by John Griffin/SBU

By Melissa Arnold

It’s been a rough year for all of us, that’s for sure, but no one has felt the sting of the COVID-19 pandemic more keenly than those who have contracted the virus.

As of Aug. 6, more than 43,000 Suffolk County residents have tested positive for COVID-19, and many more have faced the virus without an official diagnosis. Its symptoms can vary widely, from mild fatigue and chills to flu-like illnesses or even respiratory distress requiring hospital care.

The virus is unpredictable, and dealing with symptoms along with a quarantine, lengthy recovery and uncertain long-term effects is daunting. It’s only natural that many will experience tough emotions along the way.

Stony Brook Medicine is now offering a virtual support group for past and present COVID-19 patients. The weekly sessions will give patients a space to discuss their experiences and feelings while learning healthy coping mechanisms.

The support group is hosted by the Mind-Body Clinical Research Center at the Stony Brook Renaissance School of Medicine. Under the direction of founder Dr. Adam Gonzalez, the center focuses on the integration of mental and physical health for overall wellbeing.

“We wanted to see what we could do to support these members of the community who had COVID-19 and shared that they were feeling anxious, isolated and afraid of transmitting the virus to others,” Gonzalez explained. “Our goal is to provide a telehealth platform for patients to come together and bolster one another, exchange information, and learn skills to cope with stress brought on by their illness.”

Leading the group is Jenna Palladino, a licensed clinical psychologist and clinical assistant professor of psychiatry. Palladino is hopeful that participants will feel comfortable opening up about their struggles with COVID-19 in the company of others who know what it’s like.

“Research supports the idea that sharing your story helps you to work through the emotions related to it. And talking to others experiencing similar feelings helps to normalize the experience,” Palladino said. “It’s important for people going through COVID-19 to know that they’re not alone.”

The initial group is expected to run for 12 weeks, covering topics like coping with isolation, deep breathing, managing anxiety, muscle relaxation and mindfulness, to name a few.

Palladino is also leaving plenty of room for participants to ask questions and discuss topics that interest them, allowing the group to better meet their specific needs and concerns.

Gonzalez added that the support group will act as a pilot program for researchers seeking to understand the experiences of people living with COVID-19. They’ll collect data at the beginning and end of the program to see how patients are doing, if the support group was beneficial and how it can be improved.

While the initial group is limited to 10 patients, Palladino and her team are prepared to quickly begin additional groups if there is an interest, she said.

The virtual COVID-19 support group will be held from 6 to 7 p.m. Thursdays via the free Microsoft Teams video conferencing platform. The group is limited to 10 participants at a time. Registration is required to attend by calling 631-632-8657. For more information and resources, visit www.stonybrookmedicine.edu/COVID19support.

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Early diagnosis is crucial to treatment success

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

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

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

Treatment options                                             

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

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

Increased risk with diabetes drugs

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

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

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

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

Diet

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

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

References:

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

Smoking and Salt

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

Medications

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

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

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

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

Bacterial infection risks

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

B12 deficiencies

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

Lifestyle modifications

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

Obesity

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

Eating close to bedtime       

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

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

References:

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

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

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

By David Dunaief, M.D.

Dr. David Dunaief

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

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

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

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

Holes in the dairy paradigm

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

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

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

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

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

Calcium disappointments

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

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

Vitamin D benefit

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

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

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

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

References:

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

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

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