CLOSE
Tags Posts tagged with "Medical Compass"

Medical Compass

by -
0 992
Pixabay photo
Addressing issues affecting mobility are crucial to reducing risk

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease still ranks as the number 1 cause of death in the U.S., with just under 700,000 deaths per year, which equates to just over 200 deaths per 100,000 people (1). Depending on your ethnicity, your risk might be higher or lower than the average.

While this is certainly better than it used to be, we have a long way to go to reduce the risk of heart disease. 

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. 

The good news is that we have more control than we think. Most of these risks can be significantly reduced with lifestyle modifications.

Let’s look at the evidence.

Is obesity an independent risk factor?

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 those who were overweight and in those who were obese with or without metabolic syndrome, which includes a trifecta of high blood pressure, high cholesterol and high sugar levels (2). “Obese” was defined as a body mass index (BMI) over 30 kg/m², while “overweight” included those with a BMI over 25 kg/m².

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. However, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Because this was an observational trial, the results represent an association between obesity and heart disease. Basically, it’s telling us that 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.

Activity levels drive improvements

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.

How long do you suffer with 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.

When does fiber matter most?

Studies show that fiber decreases the risk of heart attacks. However, does fiber still matter once 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.

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) cdc.gov. (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. 

by -
0 1181
Long-term use of PPIs can cause dementia and chronic kidney disease. METRO photo
Over-the-counter PPIs should be taken for no more than 14 days

By David Dunaief, MD

Dr. David Dunaief

Gastroesophageal reflux disease (GERD) is one of the most commonly treated diseases in the U.S. While it is sometimes referred to as heartburn, this really a symptom. Proton pump inhibitors (PPIs), first launched in the late 1980s, have grown to become one of the top-10 drug classes prescribed or taken over-the-counter (OTC).

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 for the short term only. 

PPIs currently available OTC include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), and Aciphex (rabeprazole). These and others are also available by prescription.

The FDA indicates that OTC PPIs should be taken for no more than a 14-day treatment once every four months. Prescription PPIs should be taken for 4 to 8 weeks (1).

While PPI pre-approval trials were short-term, many take these medications long-term. 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.

Chronic kidney disease

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (2). 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 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 (3).

Dementia risk

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 (4). These patients were at least age 75. The authors surmise that PPIs may cross the 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 fracture risk

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 (5). 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 (6).

Absorption of magnesium, calcium and B12

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 (7). 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 (8). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

The bottom line

It’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as an H2 blocker (Zantac, Pepcid). In addition, PPIs may interfere with other drugs you are taking, such as Plavix (clopidogrel).

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 (9).

If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration.

References: 

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

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. 

 

by -
0 1250
Drinking milk and consuming other dairy products may actually be harmful. METRO photo
Revisiting dairy, calcium and vitamin D

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis in the U.S. is increasing as the population ages, especially among women. Why is this important? Osteoporosis may lead to increased risk of fracture due to a decrease in bone strength (1). Hip fractures are most concerning, because they increase mortality risk dramatically. In addition, more than 50 percent of hip fracture survivors lose the ability to live independently (2).

That is what we know. But what about what we think we know?

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

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

We need Vitamin D and calcium for strong bones, 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.

Let’s look more closely at what the research tells us.

Milk and dairy

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

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

This 20-year study was eye-opening. We cannot make any decisive conclusions, only associations, since it 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.

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

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

Reconsidering calcium

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 (7).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of 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 (8). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Where does that leave us?

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

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

Remember that studies, though imperfect, are better than tradition alone. 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) EndocrinePractice. 2020 May;26(supp 1):1-46. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Crit Rev Food Sci Nutr. 2020;60(10):1722-1737. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

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

by -
0 1224
Lignans found in plants can reduce risk. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

It’s always surprising the number of myths that still circulate about type 2 diabetes, considering its prevalence in the U.S. Science is continually advancing what we know about diabetes risk and disease management, and some older interpretations deserve to be retired. Let’s take a look at a few common myths and the research that debunks them.

MYTH: Fruit should be limited or avoided.

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.

MYTH: All carbohydrates raise your sugars.

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

MYTH: Soy should be avoided when you have diabetes.

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.

MYTH: Bariatric surgery is an alternative to lifestyle changes.

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. 

by -
0 1255
METRO photo
NSAIDS con contribute to kidney damage

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that the CDC estimates as many as 15 percent of U.S. adults have chronic kidney disease (CKD) and that roughly 90 percent of them don’t know they have it (1). This includes about 50 percent of people with a high risk of kidney failure in the next five years.

How is this possible? CKD is tricky because it tends to be asymptomatic, initially. Only in the advanced stages do symptoms become distinct, although there can be vague symptoms in moderate stages such as fatigue, malaise and loss of appetite. Those at highest risk for CKD include patients with diabetes, high blood pressure and those with first-degree relatives who have advanced disease. But those are only the ones at highest risk.

Why does CKD matter?

Your kidneys function as efficient little blood filters. They remove wastes, toxins and excess fluid from the body. In addition, they play roles in controlling blood pressure, producing red blood cells, maintaining bone health, and regulating natural chemicals in the blood. When they’re not operating at full capacity, the consequences can be heart disease, stroke, anemia, infection and depression — among others. According to the U.S. Preventive Services Task Force and the American College of Physicians, those who are at highest risk should be screened including patients with diabetes or hypertension (2)(3).

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.

Exercise helps – even walking

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). Even more intriguing, those who walked more often saw greater results. So, the participants who walked one-to-two times a 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 with an average age of 70, and they were followed for an average of 1.3 years.

How much protein to consume?

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

Reducing sodium consumption

Good news! In a study, results showed that a modest sodium reduction in our diet may be sufficient to help prevent proteinuria (protein in the urine) (6). Here, less than 2000 mg 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 kidney systems responsible for blood pressure and water balance (7). Results of a study show that these medications reduced the risk of death significantly in patients with moderate CKD. Most of the patients were considered hypertensive.

However, there was a high discontinuation rate among those taking the 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.

Should you be taking NSAIDs?

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

Takeaways

You don’t necessarily have to rely on drug therapies to protect your kidneys, and there is no down-side to lifestyle modifications. Lowering sodium modestly, walking frequently, and lowering your protein consumption may all be viable options, with or without medication. Discuss with your physician whether you need regular screening. High-risk patients with hypertension and diabetes should definitely be screened; however, those with vague symptoms of lethargy, aches and pains might benefit from screening, as well.

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

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

by -
0 1191
METRO photo
A daily quarter-teaspoon increase in sodium can affect kidney function

By David Dunaief, M.D

Dr. David Dunaief

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 CDC (1).

Early-stage CKD is associated with a 40 percent increased risk of developing cardiovascular events, such as heart attacks (2). 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 (3). Ultimately, it can progress to end-stage renal (kidney) disease, requiring dialysis and potentially a kidney transplant, so it’s important to identify and treat it.

However, 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 you 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. eGFR is a calculation, and while the other two indices have varying ranges depending on the laboratory used, a patient with an eGFR of 30 to 59 is considered to have mild disease. The eGFR and the kidney function are inversely related, meaning as eGFR declines, the severity of chronic kidney disease increases.

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.

Does Allopurinol help?

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 (4). 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.

A 2018 study published in the Journal of the American Medical Association, concluded that allopurinol at a dose of 300 mg or higher reduced the risk of developing stage 3 kidney disease, but less than 300 mg did not (5). However, there is a much smaller 2020 study that shows allopurinol does not help to slow the progression of CKD stage 3 patients (6). This study was very small, but it does raise a question about whether allopurinol truly works.

Diet’s impact

Fruits and vegetables may play a role in helping patients with CKD. In a one-year study with 77 patients, results showed that fruits and vegetables work as well as sodium bicarbonate in improving kidney function by reducing metabolic acidosis levels (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. Animal products tend to cause an acidic environment.

In the Nurses’ Health Study, results show that animal fat, red meat and sodium all negatively impact kidney function (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, a difference of approximately a quarter-teaspoon of sodium 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. After one month of lifestyle modifications, his eGFR improved by 9 points to 63, which is a return to “normal” functioning of the kidney. Note that this is 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 lifestyle modifications to manage and reverse early-stage CKD. If you have common risk factors, such as diabetes, smoking, obesity or high blood pressure, or if you are over 60 years old, talk to your doctor about testing. 

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

References: 

(1) CDC.gov. (2) N Engl J Med. 2004;351:1296-1305. (3) Circulation. 2004;109:320–323. (4) Clin J Am Soc Nephrol. 2010 Aug;5:1388-1393. (5) JAMA Intern Med. 2018;178(11):1526-1533. (6) N Engl J Med 2020; 382:2504-2513. (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. 

 

by -
0 1200
Pixabay photo
Most Americans underconsume potassium   

By David Dunaief, M.D.

Dr. David Dunaief

Most of us know we need to lower our sodium intake. Still, more than 90 percent of us consume far too much sodium (1). Even if we don’t have hypertension, the impact of sodium on our health can be dramatic.

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 include cold cuts and cured meats, cheeses, pizza, poultry, soups, pastas, sauces and, of course, snack foods. Processed foods and those prepared by restaurants are where most of our consumption occurs (2).

On the flip side, only about two percent of people get enough potassium from their diets (3).

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. And if you struggle with high blood pressure, this approach could help you win the battle. Let’s look at the evidence.

Why do we always harp on 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 34 randomized clinical trials, totaling more than 3,200 participants. Salt reduction from 9 to 12 grams per day to 5 to 6 grams per day, determined using 24-hour urine tests, had a dramatic effect. 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 recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

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

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, they may be telling.

Why is potassium important?

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 this was not a head-to-head comparison. The good news is that potassium is easily attainable in the diet. Foods that are potassium-rich include bananas, almonds, raisins, sweet potato and green leafy vegetables such as Swiss chard.

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

by -
0 1358
Photo from Pixabay
Medications and lifestyle changes can reduce your risk

By David Dunaief, M.D.

Dr. David Dunaief

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

Heart disease is on the decline due to a number of factors, including better awareness in lay and medical communities, improved medicines, earlier treatment of risk factors and lifestyle modifications. We are headed in the right direction, but we can do better. Heart disease is something that is eminently preventable.

Reduce your baseline risks

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

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

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

Medication’s role in reducing risk

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

In terms of lipids, statins have played a key role in primary prevention. Statins are effective at not only lowering lipid levels, including total cholesterol and LDL — the “bad” cholesterol — but also inflammation levels that contribute to the risk of cardiovascular disease. The JUPITER trial showed a 55 percent combined reduction in heart disease, stroke and mortality from cardiovascular disease in healthy patients — those with a slightly elevated level of inflammation and normal cholesterol profile — with statins.

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

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

Do lifestyle changes really help?

The Baltimore Longitudinal Study of Aging, a prospective (forward-looking) study, investigated 501 healthy men and their risk of dying from cardiovascular disease. The authors concluded that those who consumed five servings or more of fruits and vegetables daily with <12 percent saturated fat had a 76 percent reduction in their risk of dying from heart disease compared to those who did not (7). The authors theorized that eating more fruits and vegetables helped to displace saturated fats from the diet. These results are impressive and, to achieve them, they only required a modest change in diet.

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

Monitoring your heart disease risk

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

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

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

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

References: 

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

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

by -
0 1241
Inflammatory responses are at the heart of allergy symptoms        

By David Dunaief, M.D.

Dr. David Dunaief

After last week’s extended blast of winter, we’re all looking forward to warmer weather. This past weekend, we adjusted our clocks for Daylight Saving Time, the unofficial end of winter. We’re just a few weeks out from tree buds and daffodil sprouts. What joy!

However, for people who suffer from seasonal allergic rhinitis, hay fever, seasonal allergies or whatever you would like to call it, life is about to get miserable.

Just over 19 million U.S. adults were diagnosed with seasonal allergies in 2018, and an additional 5.2 million children were diagnosed, according to the Centers for Disease Control and Prevention (1).

The triggers for seasonal allergies are diverse. They include pollen from leafy trees and shrubs, grass and flowering plants, as well as weeds, with the majority from ragweed (mostly in the fall) and fungus (summer and fall) (2).

What triggers allergic reactions? 

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

The revved up immune system then responds with sneezing; red, itchy and watery eyes; scratchy throat; congestion; sinus headaches; postnasal drip; runny nose; diminished taste and smell; and even coughing (3). Basically, it emulates a cold, but without the virus. If symptoms last more than 10 days and are recurrent, then it is more than likely you have allergies.

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

Treating allergies with medications

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

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

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

Oral antihistamines, on the other hand, can be taken on an as-needed basis. Second-generation antihistamines, such as loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra), have less sleepiness as a side effect than first-generation antihistamines.

Possible alternative treatments

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

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

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

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

Can you treat allergies with diet?

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

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

References: 

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

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

by -
0 1149
Avocados are a great source of micronutrients. METRO photo
Improving calorie quality makes a difference

By David Dunaief, M.D.

Dr. David Dunaief

The road to weight loss, or even weight maintenance, is complex. Many things influence our eating behavior, including food addictions, boredom, lack of sleep and stress. This can make weight management or weight loss very difficult to achieve.

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

Does this mean we are doomed to acquiesce to food temptation? Actually, no: It is not solely about willpower. Changing diet composition is more important.

In my clinical experience, increasing the quality of food has a tremendous impact. Foods that are the most micronutrient dense, such as plant-based foods, rather than those that are solely focused on macronutrient density, such as protein, carbohydrates and fats, tend to be the most satisfying. In a week to a few months of focusing on micronutrients, one of the first things patients notice is a significant reduction in cravings. But don’t take my word for it. Let’s look at the evidence.

Refined carbohydrates

Many of us know that refined carbohydrates are not beneficial. Worse, however, a randomized control trial (RCT) showed refined carbohydrates may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown by MRI scans of trial subjects.

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

According to the authors, this effect may occur regardless of the number of calories consumed. Granted, this was a very small study, but it was well designed. High-glycemic foods include carbohydrates, such as white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates. Calorie composition matters.

Comparing macronutrients

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

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

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

Micronutrient deficiency

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

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

Cortisol levels

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

Why is this important? Cortisol is a glucocorticoid, which means it raises the level of glucose and is involved in mediating visceral or belly fat. This type of fat has been thought to coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality. This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about willpower or calorie-counting. While calories have an impact, the nutrient density of the food may be more important. Thus, those foods high in a variety of micronutrients may also play a significant role in reducing cravings, ultimately helping to manage weight.

References: 

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

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

Prev1...151617...41Next Page 16 of 41
TBR News Media is your local news and entertainment website.
We provide you with the latest breaking news and information for your community.
Contact us: [email protected]

Most Viewed

©