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Medical Compass

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Modest alcohol consumption may decrease stroke risk in women

By David Dunaief

Dr. David Dunaief

Alcohol is one of the most widely used over-the-counter drugs, and there is much confusion over whether it is beneficial or detrimental to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing. 

Several studies have been published – some touting alcohol’s health benefits, with others warning of its risks. The diseases addressed by these studies include breast cancer, heart disease and stroke. Remember, context is the determining factor for alcohol intake.

Breast Cancer Impact

In a meta-analysis of 113 studies, there was an increased risk of breast cancer with daily consumption of alcohol (1). The increase was a modest, but statistically significant, four percent, and the effect was seen at one drink or less a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.

It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increases the risk of breast cancer modestly over a 28-year period (2). This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer. The risk was dose-dependent, with one to two drinks per day increasing risk to 22 percent, while those having three or more drinks per day had a 51 percent increased risk.

Alcohol’s impact on breast cancer risk is being actively studied, considering types of alcohol, as well as other mitigating factors that may increase or decrease risk. We still have much to learn.

Based on what we think we know, if you are going to drink, a drink several times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes the effect, although it might (3).

Stroke Effects

On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol (4). This analysis involved over 83,000 women. Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers. 

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

Moderation is the key.
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Heart effects

In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more or were non-drinkers (5). Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits. This study has a high durability spanning 20 years.

Citrus benefits rival alcohol benefits for stroke risk

An analysis of the Nurses’ Health Study recently showed that those who consumed more citrus fruits had approximately a 19 percent reduction in stroke risk (6). These results were similar to the reduction seen in the Nurses’ Health Study with modest amounts of alcohol.

The citrus fruits used most often in this study were oranges and grapefruits. Of note, grapefruit may interfere with medications such as Plavix (clopidogrel), a commonly used antiplatelet medication used to prevent strokes (7). Grapefruit inhibits the CYP3A4 system in the liver, thus increasing the levels of certain medications.

Alcohol in Moderation

Moderation is the key. It is very important to remember that alcohol is a drug that does have side effects, including insomnia. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more. To get the stroke benefits and avoid the increased breast cancer risk, half a glass of alcohol per day may be the ideal amount for women. Moderate amounts of alcohol for men are up to two glasses daily, though one glass showed significant benefits. 

Remember, there are other ways of reducing your risk of these maladies that don’t require alcohol. However, if you enjoy alcohol, moderate amounts may reap some health benefits.

References:

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

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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Regular exercise is an important way to lower your risk of heart disease. METRO photo
Addressing weight and mobility issues may lower risk

By David Dunaief, M.D.

Dr. David Dunaief

We have made great strides in reducing heart attack mortality. When we compare cardiovascular disease — heart disease and stroke — mortality rates since 1975 to present, there has been a substantial decline. However, since 1990, the rate of decline has slowed (1). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. Obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. Less obvious ones include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, may help allay the risks.

Let’s look at the evidence.

Address obesity

Obesity continually gets play in discussions of disease risk. But how substantial a risk factor is it?

In the Copenhagen General Population Study, results showed an increased heart attack risk in obese (BMI >30 kg/m²) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m²) (2). The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” This was an observational trial, so we can only make an association; however, if it is true, then there may not be such a thing as a “metabolically healthy” obese patient. If you are obese, this is one of many reasons that it’s critical to lose weight.

Get moving

Let’s consider another lifestyle factor, the impact of being sedentary. An observational study found that activity levels had a surprisingly high impact on women’s heart disease risk (3). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over age 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported, it may have been underestimated as a risk factor. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Manage osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? In a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack (4). Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

Increase fiber

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (5).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is that those who increased their fiber after a cardiovascular event had a 31 percent reduction in mortality risk. The most intriguing part of the study was the dose response. For every 10-gram increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events such as heart attacks (6).

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References:

(1) Heart. 1998;81(4):380. (2) JAMA Intern Med. 2014;174(1):15-22. (3) Br J Sports Med. 2014, May 8. (4) PLoS ONE. 2014, Mar 14, 2014. [https://doi.org/10.1371/journal.pone.0091286]. (5) BMJ. 2014;348:g2659. (6) N Engl J Med. 2000;343(1):16.

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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Chest pain remains the most common symptom in both men and women 

By David Dunaief, M.D.

Dr. David Dunaief

When we refer to heart disease, it is an umbrella term; heart attacks are one component. 

Fortunately, the incidence of heart attacks has decreased over the last several decades, as have deaths from heart attacks. However, there are still 790,000 heart attacks every year, and almost three-quarters of these are first heart attacks (1).

If you think someone is having a heart attack, call 911 as quickly as possible and have the patient chew an adult aspirin (325 mg) or four baby aspirins. While the Food and Drug Administration does not recommend aspirin for primary prevention of a heart attack, the use of aspirin here is for treatment of a potential heart attack, not prevention.

Heart attack symptoms

The main symptom is chest pain, which most people don’t have trouble recognizing. However, there are a number of other, more subtle, symptoms such as discomfort or pain in the jaw, neck, back, arms and epigastric, or upper abdominal areas. Others include nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate). One problem is that less than one-third of people know these other major symptoms (2). About 10 percent of patients present with atypical symptoms — without chest pain — according to one study (3).

It is not only difficult for the patient but also for the medical community, especially the emergency room, to determine who is having a heart attack. Fortunately, approximately 80 to 85 percent of chest pain sufferers are not having a heart attack. More likely, they have indigestion, reflux or other non-life-threatening ailments.

There has been a raging debate about whether men and women have different symptoms when it comes to heart attacks. Several studies speak to this topic.

Men vs. women

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish prospective (forward-looking) study, after having a heart attack, a significantly greater number of women died in hospital or near-term when compared to men. The women received reperfusion therapy, artery opening treatment that consisted of medications or invasive procedures, less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram; they both had what we call ST elevations. This was a study involving approximately 54,000 heart attack patients, with one-third of them being women.

One theory about why women are treated less aggressively when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. Women’s symptoms may include pain in the lower portion of the chest or upper portion of the abdomen, and they may have significantly less severe pain that could radiate or spread to the arms. But, is this true? Not according to several studies.

In one observational study, results showed that, though there were some subtle differences in chest pain, on the whole, when men and women presented with this main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: The duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The study included approximately 2,500 patients, all of whom had chest pain. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. The population difference was a conspicuous weakness of an otherwise solid study, since age and previous heart attack history are important factors.

In the GENESIS-PRAXY study, another observational study, but with a younger population, the median age of both men and women was 49. Results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings (non-ST elevations), significantly more were women than men. Those who did not have chest pain symptoms may have had some of the following symptoms: back discomfort, weakness, discomfort or pain in the throat, neck, right arm and/or shoulder, flushing, nausea, vomiting and headache.

If the patients did not have chest pain, regardless of sex, the symptoms were diffuse and nonspecific. The researchers were looking at acute coronary syndrome, which encompasses heart attacks. In this case, independent risk factors for disease not related to chest pain included both tachycardia (rapid heart rate) and being female. The authors concluded that there need to be better ways to calibrate non-chest pain symptoms.

Some studies imply that as much as 35 percent of patients do not present with chest pain as their primary complaint (7).

Let’s summarize

So what have we learned about heart attack symptoms? The simplest lessons are that most patients have chest pain, and that both men and women have similar types of chest pain. However, this is where the simplicity stops and the complexity begins. The percentage of patients who present without chest pain seems to vary significantly depending on the study — ranging from less than 10 percent to 35 percent.

Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. When it comes to heart attacks, suspicion should be based on the same symptoms for both sexes. Therefore, know the symptoms, for it may be your life or a loved one’s that depends on it.

References:

(1) cdc.gov. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA. 2012;307:813-822.

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

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Long-term proton pump inhibitor use may have serious side effects

By David Dunaief, M.D.

Dr. David Dunaief

Reflux (GERD) disease, sometimes referred to as heartburn, though this is more of a symptom, is one of the most commonly treated diseases. In line with this, proton pump inhibitors (PPIs) have become one of the top-10 drug classes prescribed or taken in the United States.

The class of drugs called PPIs includes Prevacid (lansoprazole), Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). Several of these medications are now available over-the-counter, rather than by prescription. When they were first approved, they were touted as having one of the cleanest side-effect profiles. This may still be true, if we use them correctly. They are intended to be used only for the short term. This can range from 7 to 14 days for over-the-counter PPIs to 4 to 8 weeks for prescription PPIs.

Dangers of long-term use

While PPI pre-approval trials were short-term, not longer than a year, many physicians put patients on these medications for decades. And the longer people are on them, the more complications arise. Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

Though PPIs may increase the risk of a number of complications, keep in mind that none of the data are from randomized controlled trials (RCTs), which are the gold standard of studies, but mostly observational studies that suggest an association, not a link.

Chronic kidney disease

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (1). All of the patients started the study with normal kidney function based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a modest 17 percent increased risk. 

The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (2).

Dementia

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A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (3). These patients were at least age 75. The authors surmise that PPIs may cross the coveted blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk. Researchers also did not take into account family history of dementia, high blood pressure or excessive alcohol use, all of which have effects on dementia occurrence.

Bone fractures

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (4). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption through the gut. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (5).

Need for magnesium

PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (6). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

Another study confirmed these results. In this second study, which was a meta-analysis of nine studies, PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (7). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

The bottom line is that it’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as H2 blockers (Zantac, Pepcid). Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (8).

If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration: 7 to 14 days, according to the FDA, without a doctor’s consult, and 4 to 8 weeks with one (9).

References:

(1) JAMA Intern Med. 2016;176(2). (2) JAMA Intern Med. 2016;176(2):172-174. (3) JAMA Neurol. online Feb 15, 2016. (4) Osteoporos Int. online Oct 13, 2015. (5) Am J Med. 118:778-781. (6) PLoS Med. 2014;11(9):e1001736. (7) Ren Fail. 2015;37(7):1237-1241. (8) Am J Gastroenterol 2015; 110:393–400. (9) fda.gov.

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

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Do calcium supplements help?

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis is increasing, especially as the population ages. Why is this important? Osteoporosis may lead to increased risk of fracture due to a decrease in bone strength (1). That is what we do know. But what about what we think we know?

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

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

Does milk help or hurt?

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (2). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, three percent per glass increased risk of death in men. Women experienced a small, but significant, increased risk of hip fracture, but no in-creased 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 three cups of dairy per day (3). 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 (4).

Does calcium help?

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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 (5).

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 taken into account.

What about vitamin D?

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 (6). 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 ex-ample 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) JAMA. 2001;285:785-795. (2) BMJ 2014;349:g6015. (3) health.gov (4) JAMA Pediatr. 2014;168(1):54-60. (5) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (6) 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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rapes have been found to reduce glucose levels. Pexels photo
Whole berries may reduce glucose levels the most

By David Dunaief, M.D.

Dr. David Dunaief

Type 2 diabetes is pervasive throughout the population, affecting adults, but also children and adolescents. Yet, even with its prevalence, many myths persist about managing diabetes.

Among these are: Fruit should be limited or avoided; Soy has detrimental effects with diabetes; Plant fiber provides too many carbohydrates; and Bariatric surgery is an alternative to lifestyle changes.

All of these statements are false. My goal is to help debunk these type 2 diabetes myths. Let’s look at the evidence.

Fruit

Fruit, whether whole fruit, fruit juice or dried fruit, has been long considered taboo for those with diabetes. This is only partially true. Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (2).

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

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

Fiber

We know fiber is important for reducing risk for a host of diseases and for managing their outcomes, and it is not any different for diabetes. 

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

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

Soy and kidney function

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

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

This is very important since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

Bariatric surgery

Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery involving 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintaining long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order to sustain its benefits.

References:

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

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

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Walking may reduce the need for dialysis. METRO photo
Simple lifestyle changes can have an impact

By David Dunaief, M.D.

Dr. David Dunaief

On the heels of National Kidney Month in March, let’s look more closely at strategies for reducing chronic kidney disease (CKD). Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease. But those are only the ones at highest risk.

CKD is tricky because, similar to high blood pressure and dyslipidemia (high cholesterol), it tends to be asymptomatic, at least initially. Only in the advanced stages do symptoms become distinct, though there can be vague symptoms in moderate stages such as fatigue, malaise and loss of appetite.

What are the CKD stages?

CKD is classified into five stages based on the estimated glomerular filtration rate (eGFR), a way to determine kidney function. Stages 1 and 2 are the early stages, while stages 3a and 3b are the moderate stages, and finally stages 4 and 5 are the advanced stages. Stage 5 is end-stage renal disease, or kidney failure.

Who should be screened?

According to the U.S. Preventive Services Task Force and the American College of Physicians, those who are at highest risk should be screened including, as I mentioned above, patients with diabetes or hypertension (1)(2). 

In an interview on Medscape.com, “Proteinuria: A Cheaper and Better Cholesterol?” two high-ranking nephrologists suggest that first-degree relatives to advanced CKD patients should also be screened and that those with vague symptoms of fatigue, malaise and/or decreased appetite may also be potential screening candidates (3). This broadens the asymptomatic population that may benefit from screening.

Slowing CKD progression

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

How much exercise?

Here we go again, preaching the benefits of exercise. But what if you don’t really like exercise? It turns out that the results of a study show that walking reduces the risk of death and the need for dialysis by 33 percent and 21 percent respectively (4). And although some don’t like formal exercise programs, most people agree that walking is enticing.

The most prevalent form of exercise in this study was walking. Even more intriguing, the results are based on a dose-response curve. In other words, those who walked more often saw greater results. So, the participants who walked one-to-two times per week had a significant 17 percent reduction in death and a 19 percent reduction in kidney replacement therapy, while those who walked at least seven times per week experienced a more impressive 59 percent reduction in death and a 44 percent reduction in the risk of dialysis. There were 6,363 participants for an average duration of 1.3 years.

How much protein to consume?

When it comes to CKD, more protein is not necessarily better, and may even be harmful. In a meta-analysis (a group of 10 randomized controlled trials) of Cochrane database studies, results showed that the risk of death or treatment with dialysis or kidney transplant was reduced by 32 percent in those who consumed less protein compared to unrestricted protein (5). According to the authors, as few as two patients would need to be treated for a year in order to prevent one from either dying or reaching the need for dialysis or transplant.

Sodium: How much is too much?

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

Medications have a place

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

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

While these two classes of medications, ACE inhibitors and ARBs, are good potential options for protecting the kidneys, they are not the only options. You don’t necessarily have to rely on drug therapies, and there is no downside to lifestyle modifications. Lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options, with or without medication, since medication compliance was woeful. Screening for asymptomatic, moderate CKD may lack conclusive studies, but screening should occur in high-risk patients and possibly be on the radar for those with vague symptoms of lethargy as well as aches and pains. Of course, this is a discussion to have with your physician.

References:

(1) uspreventiveservicestaskforce.org (2) aafp.org. (3) Medscape.com. (4) Clin J Am Soc Nephrol. 2014;9(7):1183-9. (5) Cochrane Database Syst Rev. 2009;(3):CD001892. (6) Curr Opin Nephrol Hypertens. 2014;23(6):533-540. (7) J Am Coll Cardiol. 2014;63(7):650-658.

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

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There are many fruits and vegetables that are beneficial for kidney health. METRO photo
Increasing fruits and vegetables may protect kidneys

By David Dunaief, M.D.

Dr. David Dunaief

Chronic kidney disease is on the rise in this country. Approximately 37 million U.S. adults have chronic kidney disease (CKD), with as many as 9 in 10 not aware they have it, according to the Centers for Disease Control and Prevention (CDC) (1). In this article, we will look beyond the more obvious causes of chronic kidney disease, like diabetes, smoking, aging, obesity and high blood pressure (2).

Why is early-stage CKD so important? It is associated with a 40 percent increased risk of developing cardiovascular events, such as heart attacks (3). It also significantly increases the risk of peripheral artery disease (PAD). Those with decreased kidney function have a 24 percent prevalence of PAD, compared to 3.7 percent in those with normal kidney function (4). Of course, it can lead ultimately to end-stage renal (kidney) disease, requiring dialysis and potentially a kidney transplant.

One of the problems with early-stage CKD is that it tends to be asymptomatic. However, there are simple tests, such as a basic metabolic panel and a urinalysis, that will indicate whether a patient may have mild chronic kidney disease. These indices for kidney function include an estimated glomerular filtration rate (eGFR), creatinine level and protein in the urine. While the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 mL/minute/1.73 m2 is considered to have mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the more severe the chronic kidney disease.

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

Leveraging Medications

Allopurinol is usually thought of as a medication to prevent gout. However, in a randomized controlled trial, with 113 patients, results show that allopurinol may help to slow the progression of CKD, defined in this study as an eGFR less than 60 mL/min/1.73 m2 (5). The group using 100 mg of allopurinol showed significant improvement in eGFR levels (compared to the control group over a two-year period. The researchers concluded that allopurinol slowed CKD progression. Allopurinol also decreased cardiovascular risk by 71 percent.

Fibrates are a class of drug usually used to boost HDL (“good”) cholesterol levels and reduce triglyceride levels, another cholesterol marker. Fibrates have gotten negative press for not showing improvement in cardiovascular outcomes. However, in patients with mild to moderate CKD, a meta-analysis (a group of 10 studies) showed a 30 percent reduction in major cardiovascular events and a 40 percent reduction in the risk of cardiovascular mortality with the use of fibrates (6). This is important, since patients with CKD are mostly likely to die of cardiovascular disease.

The authors concluded that fibrates seem to have a much more powerful beneficial effect in CKD patients, as opposed to the general population. So, there may be a role for fibrates after all.

Diet’s impact

Fruits and vegetables may play a role in helping patients with CKD. In one study, the results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (7).

What is the significance of metabolic acidosis? It means that body fluids become acidic, and it is associated with chronic kidney disease. The authors concluded that both sodium bicarbonate and a diet including fruits and vegetables were renoprotective, helping to protect the kidneys from further damage in patients with CKD. Alkali diets are primarily plant-based, although not necessarily vegetarian or vegan diets. Animal products tend to cause an acidic environment. The study was one year in duration with 77 patients.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (8). The risk of protein in the urine, a potential indicator of CKD, increased by 72 percent in those participants who consumed the highest amounts of animal fat compared to the lowest, and by 51 percent in those who ate red meat at least twice a week. With higher amounts of sodium, there was a 52 percent increased risk of having lower levels of eGFR.

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

In my practice, when CKD patients follow a vegetable-rich, nutrient-dense diet, there are substantial improvements in kidney functioning. For instance, for one patient, his baseline eGFR was 54 mL/min/1.73 m2. After one month of lifestyle modifications, his eGFR improved by 9 points to 63 mL/min/1.73 m2, which is a return to “normal” functioning of the kidney. Note that this is an anecdotal story and not a study.

Therefore, it is important to have your kidney function checked with mainstream tests. If the levels are low, you should address the issue through medications and/or lifestyle modifications to manage and reverse early-stage CKD. Don’t wait until symptoms and complications occur. In my experience, it is much easier to treat and reverse a disease in its earlier stages, and CKD is no exception.

References:

(1) CDC.gov. (2) JAMA. 2004;291:844-850. (3) N Engl J Med. 2004;351:1296-1305. (4) Circulation. 2004;109:320–323. (5) Clin J Am Soc Nephrol. 2010 Aug;5:1388-1393. (6) J Am Coll Cardiol. 2012 Nov. 13;60:2061-2071. (7) Clin J Am Soc Nephrol. 2013;8:371-381. (8) Clin J Am Soc Nephrol. 2010; 5:836-843.

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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Bananas are rich in potassium. METRO photo
Most Americans don’t consume enough potassium

By David Dunaief, M.D.

Dr. David Dunaief

With all the focus on reducing sodium in our diets, the importance of consuming potassium gets short shrift. 

More than 90 percent of people consume far too much sodium, with salt being the primary culprit (1). Sodium is insidious; it’s in foods that don’t even taste salty. Bread products are among the primary offenders. Other foods with substantial amounts of sodium are cold cuts and cured meats, cheeses, pizza, poultry, soups, pastas and, of course, snack foods. Processed foods and those prepared by restaurants are where most of our consumption occurs (2).

On the flip side, only about two percent of people get enough potassium from their diets (3). According to one study, we would need to consume about eight sweet potatoes or 10 bananas each day to reach appropriate levels. 

Why is it important to reduce sodium and increase potassium? A high sodium-to-potassium ratio increases the risk of cardiovascular disease by 46 percent, according to the study, which looked at more than 12,000 Americans over almost 15 years (4). In addition, both may have significant impacts on blood pressure and cardiovascular disease.

To improve our overall health, we need to shift the sodium-to-potassium balance so that we consume more potassium and less sodium. Let’s look at the evidence.

Reduce your sodium

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

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

This was a meta-analysis (a group of studies) that evaluated data from randomized clinical trials, the gold standard of studies. There were 34 trials reviewed with more than 3,200 participants. Salt was reduced from 9 to 12 grams per day to 5 to 6 grams per day. These levels were determined using 24-hour urine tests. The researchers believe there is a direct linear effect with salt reduction. In other words, the more we reduce the salt intake, the greater the effect of reducing blood pressure. The authors concluded that these effects on blood pressure will most likely result in a decrease in cardiovascular disease.

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

In an epidemiology modeling study, the researchers projected that either a gradual or instantaneous reduction in sodium would save lives (7). For instance, a modest 40 percent reduction over 10 years in sodium consumed could prevent 280,000 premature deaths. These are only projections, but in combination with the above studies may be telling. The bottom line: decrease sodium intake by almost half and increase potassium intake from foods.

Increase your potassium

When we think of blood pressure, not enough attention is given to potassium. The typical American diet doesn’t contain enough of this mineral.

In a meta-analysis involving 32 studies, results showed that as the amount of potassium was increased, systolic blood pressure decreased significantly (8). When foods containing 3.5 to 4.7 grams of potassium were consumed, there was an impressive −7.16 mm Hg reduction in systolic blood pressure with high blood pressure patients. Anything more than this amount of potassium did not have any additional benefit. Increased potassium intake also reduced the risk of stroke by 24 percent. This effect was important.

The reduction in blood pressure was greater with increased potassium consumption than with sodium restriction, although there was no head-to-head comparison done. The good news is that potassium is easily attainable in the diet. Foods that are potassium-rich include bananas, sweet potatoes, almonds, raisins and green leafy vegetables such as Swiss chard.

Lowering sodium intake may have far-reaching benefits, and it is certainly achievable. First, consume less and give yourself a brief period to adapt — it takes about six weeks to retrain your taste buds, once you cut your sodium. You can also improve your odds by increasing your dietary potassium intake, which also has a substantial beneficial effect, striking a better sodium-to-potassium balance.

References:

(1) Am J Clin Nutr. 2012 Sep;96(3):647-657. (2) www.cdc.gov. (3) Am J Clin Nutr. 2012 Sep;96(3):647-657. (4) Arch Intern Med. 2011;171(13):1183-1191. (5) BMJ. 2013 Apr 3;346:f1325. (6) BMJ. 2013 Apr 3;346:f1326. (7) Hypertension. 2013; 61: 564-570. (8) BMJ. 2013; 346:f1378.

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

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Osteoarthritis osteoarthritis affects joints in your hands, knees, hips and spine. METRO photo

By David Dunaief

Dr. David Dunaief

Osteoarthritis most commonly affects the knees, hips and hands. If you suffer from it, you know it can be painful to perform daily tasks or to get around. There are some surgical solutions, such as joint replacements of the hips or knees, as well as medical approaches with pain medications. The most commonly used first-line medications are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, while medications treat the immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression, and they do have side effects, especially with long-term use.

Here, we’ll focus on nonpharmacologic approaches you can use to ease pain — and perhaps slow worsening of your osteoarthritis.

Does dairy help or hurt?

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

In the Osteoarthritis Initiative study, an observational study of over 2,100 patients, results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women (1). The researchers looked specifically at joint space narrowing that occurs in those with affected knee joints. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.

Osteoarthritis affects joints in your hands, knees, hips and spine. METRO photo

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

However, the study had significant flaws. First, the patients were only asked about their milk intake at the study’s start. Second, patients were asked to recall their weekly milk consumption for the previous 12 months before the study began — a challenging task. Third, confounding factors, such as orange consumption, were not examined.

On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (2).

Getting more specific, a recently published analysis of the Framingham Offspring Study found that those who consumed yogurt had statistically significant lower levels of interleukin-6 (IL-6), a marker for inflammation, than those who didn’t eat yogurt, but that this was not true with milk or cheese consumption (3).

We are left with more questions than answers. Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I may not dissuade osteoarthritis patients from yogurt.

Vitamin D

Over the last decade, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief, nor any disease-modifying effects (4). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

Weight loss

This could not be an article on osteoarthritis if I did not talk about weight. In a study involving 112 obese patients, there was not only a reduction of knee symptoms in those who lost weight, but there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5).

On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet

In a study, diet and exercise trumped the effects of diet or exercise alone (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a well-designed, randomized controlled single-blinded study with a duration of 18 months.

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

Therefore, concentrate on lifestyle modifications if you want to see potentially disease-modifying effects. These include both exercise and diet. In terms of low-fat or nonfat milk, the results are controversial at best. For yogurt, the results suggest it may be beneficial for osteoarthritis, but stay on the low end of consumption. And remember, the best potential effects shown are with weight loss and with a vegetable-rich diet.

References:

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

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

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