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Medical Compass

Sodium’s effects are insidious

By David Dunaief, M.D.

Dr. David Dunaief

Most of us consume far too much sodium. Americans consume an average of 3400 mg per day, well over the recommended 2300 mg per day recommended upper limit for those who are 14 and over (1). These consumption numbers are even higher for some demographics. It’s become such a health problem that the FDA is getting involved, working with food manufacturers and restaurants to drive these numbers down (2). 

Why all the concern? Because even if we don’t have hypertension, sodium can have a dramatic impact on our health.

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

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

What is the relationship between sodium and potassium?

A high sodium-to-potassium ratio increases our risk of cardiovascular disease by 46 percent, according to a 15-year study of more than 12,000 (4). 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 – or are at risk for – high blood pressure, this approach could help you win the battle.

Why lower your sodium consumption?

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

The first was a meta-analysis that evaluated data from 34 randomized clinical trials, totaling more than 3,200 participants. It demonstrated that salt reduction from 9-to-12 grams per day to 5-to-6 grams per day had a dramatic effect. Blood pressure was 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 reduction of −2.82 mm Hg. The researchers believe that the more we reduce the salt intake, the greater the effect of reducing blood pressure. The authors recommend further reduction to 3 grams per day as a long-term target for the population and concluded that the effects on blood pressure will most likely result in a decrease in cardiovascular disease.

In the second study, a meta-analysis of 42 clinical trials including both adults and children, there was a similarly significant reduction in both systolic and diastolic blood pressures (6). Both demographics saw a blood pressure reduction, although 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.

Can you consume too little sodium?

Some experts warn that too-low sodium levels can be a problem. While this is true, it’s very rare, unless you take medication or have a health condition that depletes sodium. We hide sodium everywhere, so even if you don’t use a salt shaker, you’re probably consuming more than the recommended amount of sodium.

Why is potassium consumption important?

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

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

The bottom line: decrease your sodium intake and increase potassium intake from foods. First, consume less sodium, and give yourself a brief period to adapt — it takes about six weeks to retrain your taste buds. You can also improve your odds by increasing your dietary potassium intake, striking a better sodium-to-potassium balance.


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

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

Exercise and diet are keys to improving discomfort for osteoarthritis pain. METRO photo
Exercise and diet are keys to improving discomfort

By David Dunaief, M.D.

Dr. David Dunaief

Osteoarthritis (OA) can make it difficult to perform daily activities and affect your quality of life. It affects the knees, hips and hands most often, and it can disturb your mobility, mood, and sleep quality.

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

However, you can ease your pain without reaching for medications. Some approaches might even help slow you OA’s progression or reverse your symptoms.

Does losing weight really help with OA pain?

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

The relationship was almost one-to-one; for every one percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the opposite occurred when participants gained weight.

A reduction of tibial cartilage is often associated with the need for a knee replacement.

Does increasing vitamin D help reduce OA pain?

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

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

Does consuming dairy help with OA?

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

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

The result curve was interesting, however. For those who drank 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 benefit. There was no benefit seen in men or with the consumption of higher fat products, such as cheese or yogurt.

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

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

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

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

Which is better, diet or exercise, for reducing OA pain?

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

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

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


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

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

Try eating a more plant-based, whole foods diet. METRO photo
Cardiac biomarkers can help you monitor your progress

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is on the decline in the U.S. Several factors have influenced this, including better awareness, improved medicines, earlier treatment of risk factors and lifestyle modifications (1). Still, we can do better. Heart disease still underpins one in four deaths, and it is preventable.

What are the baseline risks for heart disease?

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 rates are increasing. For patients with type 2 diabetes, 70 percent die of cardiovascular causes (2).

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

A less-discussed risk factor is a resting heart rate greater than 80 beats per minute (bpm). A normal resting heart rate is typically between 60 and 100 bpm. If your resting heart rate is in the high-normal range, your risk increases.

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). The good news is that you can reduce your risks.

Does medication lower heart disease risk?

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

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

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

Unfortunately, another side effect of statins is myopathy (muscle pain). I have a number of patients who suffered from statin muscle pain and cramps shift their focus to diet and exercise to get off their prescriptions. Lifestyle modification is a powerful ally.

Do lifestyle changes really reduce heart disease risk?

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 modest dietary changes.

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 was dose-dependent, meaning the more parameters adopted, the greater the risk reduction. SCD risk was reduced up to 92 percent when all four parameters were followed (8). Thus, it is possible to almost eliminate the risk of SCD for women with lifestyle modifications.

How can you monitor your progress in lowering heart disease risk?

To monitor your progress, cardiac biomarkers, such as blood pressure, cholesterol, body mass index, and inflammatory markers like C-reactive protein can tell us a lot.

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

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


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

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

Pixabay image
Antibiotic use can affect the microbiome

By David Dunaief, M.D.

Dr. David Dunaief

Each of us has a microbiome — trillions of microbes that include bacteria, viruses and single-cell eukaryotes that influence our body’s functions. When “good” and “bad” microbes are in balance, we operate without problems. However, when the balance is tipped, often by environmental factors, such as diet, infectious diseases, and antibiotic use, it makes us more susceptible to diseases and disorders.

While the microbiome is found throughout our bodies, including the skin, the eyes and the gut, we’re going to focus on the gut, where most of our microbiome lives.

Research into the specifics of our microbiome’s role in healthy functioning is still in its infancy. Current research into the microbiome’s effects include its role in obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

What influences our microbiome?

Lifestyle, such as diet, can impact our microbiome positively or negatively. Microbiome diversity may be significantly different in distinct geographic locations throughout the world, because diet and other environmental factors play such a large role.

When we take drugs, such as antibiotics, we can wipe out our microbial diversity, at least in the short term. This is why many have gastrointestinal upset while taking antibiotics. Antibiotics don’t differentiate between good and bad bacteria when they go to work.

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

How does the microbiome affect weight?

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

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

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

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

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

Does gut bacteria contribute to the development of rheumatoid arthritis?

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

Although we can’t yet say what the ideal gut bacteria should consist of, we do know a few things that can help you. Diet and other lifestyle considerations, such as eating and sleeping patterns or their disruptions, can affect the composition and diversity of gut bacteria (4). Studies have already demonstrated prebiotic effects of fiber and significant short-term changes to the microbiome when eating fruits, vegetables, and plant fiber. The research is continuing, but we’ve learned a lot already.


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

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

METRO photo
There are alternatives to sealing yourself indoors

By David Dunaief, M.D.

Dr. David Dunaief

It is officially Spring! Locally, trees are budding, and flowers are beginning to bloom in full force.

If you suffer from seasonal allergies – also known as allergic rhinitis or hay fever – going for a walk is probably a little less enjoyable.

Roughly 25 percent of U.S. adults and 18.9 percent of children were diagnosed with seasonal allergies in 2021, according to the Centers for Disease Control and Prevention (1).

There are quite a few triggers for seasonal allergies. 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 causes allergic reactions? Seasonal allergy sufferers experience a chain reaction when they inhale allergens (pollen, in this case). The pollen interacts with immunoglobulin E (IgE), antibodies that are part of our immune system and causes 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 feels like a common cold, but without the virus. If you have symptoms that last more than 10 days and are recurrent, then it is more likely you have allergies than a virus.

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

Do medications really help with allergies? The best way to treat allergy attacks is to prevent them, but this means sealing yourself inside. You will need to close the windows, use your air conditioning and, when you do go out, use the recycling vents in your car.

On the medication side, we have intranasal glucocorticoids (steroids), oral antihistamines, allergy shots, decongestants, antihistamine and decongestant eye drops.

The guidelines for treating seasonal allergic rhinitis with medications suggest that you use intranasal corticosteroids (steroids) when your quality of life is affected (5). Two well-known inhaled steroids are triamcinolone (Nasacort) and fluticasone propionate (Flonase). While inhaled steroids are probably most effective in treating and preventing symptoms, they need to be used every day and can have side effects, like headaches.

If you experience itchiness and sneezing, then second-generation oral antihistamines may be appropriate. These 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, like Benadryl, but they don’t work for everyone.

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

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

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

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

Can you treat seasonal 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 in teens, specifically rhinoconjunctivitis, affecting the nose and eyes, as well as eczema and asthma (9). In my clinical practice, many patients with seasonal allergies have improved and even reversed the course of allergies over time with a vegetable-rich, plant-based diet. This might be due to its anti-inflammatory effects. Analogously, some physicians suggest that their patients have improved after removing dairy from their diets.

While allergies can make you miserable, there are a significant number of over-the-counter and prescription options to help. Diet may play a role by reducing inflammation, although there are no formal studies. There does seem to be promise with some herbs, like butterbur, although there are caveats. Always consult your doctor before starting any supplements, herbs or over-the-counter medications.

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

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

A lack of exercise may rewire our brains. METRO image

By David Dunaief, M.D.

Dr. David Dunaief

Are 20-somethings more quick-witted than people over 60? You might be surprised by what the research actually tells us. Fear of — and assumptions about —cognitive decline as we age are common. They’re so common that entire industries focus on selling us supplements and games to keep us sharp. Ageism is also a growing concern in society and in the workplace.

What do we really know about the brain? We know that certain drugs, head injuries and lifestyle choices can have negative effects. Numerous neurological, infectious, and rheumatologic disorders and diseases can also have long-term brain effects. These include autoimmune disorders, psychiatric mood disorders, diabetes and heart disease.

Of course, addressing the underlying medical issue is critical. Fortunately, several studies also suggest that we may be able to help our brains function more effectively with rather simple lifestyle changes: sleep, exercise and possibly omega-3s.

What is brain clutter?

Let’s return to our question comparing those in their 20s with those over 60.

German researchers put this stereotype to the test. They found that educated older people tend to have a larger mental database of words and phrases to draw upon when responding to a question (1). When this was factored into their simulation analysis, the difference in terms of age-related cognitive decline became negligible.

The more you know, the harder it becomes to come up with a simple answer to something.

What if we could reboot our brains, just like we do with a computer? This may be possible through sleep, exercise and omega-3s.

How does sleep help with brain functioning?

Researchers have identified a couple of specific values we receive from sleep: one involves clearing the mind, and another involves productivity.

For the former, a study done in mice shows that sleep may help the brain remove waste, such as beta-amyloid plaques (2). When we have excessive plaque buildup in the brain, it may be a sign of Alzheimer’s. When mice were sleeping, the interstitial space (the space between brain structures) increased by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough, because cerebrospinal fluid could reach much farther. A similar effect was seen when the mice were anesthetized.

In an Australian study, results showed that sleep deprivation may have contributed to an almost one percent decline in gross domestic product (3). Why? When people don’t get enough sleep, they are not as productive. They tend to be more irritable, and their concentration may be affected. While we may be able to turn on and off sleepiness on short-term basis, we can’t do this continually.

In one small study, sleep deprivation was compared to alcohol impairment (4). It found that subjects’ response time and accuracy with assigned tasks after 17-19 hours without sleep were comparable or worse than their performance when they had a blood-alcohol concentration (BAC) of .05 percent. With more than 19 hours of sleeplessness, performance equaled .1 percent BAC.

Earlier studies showing similar results led my wife to insist on picking me up, rather than letting me drive home, after 24-hour call hospital assignments during my residency. 

Does lack of exercise rewire your brain?

One study with rats suggests that a lack of exercise can cause unwanted new brain connections. Rats that were not allowed to exercise were found to have rewired neurons around their medulla, the part of the brain involved in breathing and other involuntary activities. This included more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (5). 

Among the rats allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart. We need human studies to confirm this impact.

Do omega-3 fatty acids improve brain volume?

The hippocampus is involved in memory and cognitive function. In the Women’s Health Initiative Memory Study of Magnetic Resonance Imaging Study, results showed that postmenopausal women who were in the highest quartile of measured omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (6). 

Specifically, the researchers looked at the levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes. The source of the omega-3 fatty acids could have been from either fish or supplementation.

It’s never too late to improve brain function. Although we have a lot to learn, we know that there are relatively simple ways we can positively influence it.


(1) Top Cogn Sci. 2014 Jan.;6:5-42. (2) Science. 2013 Oct. 18;342:373-377. (3) Sleep. 2006 Mar.;29:299-305. (4) Occup Environ Med. 2000 Oct;57(10):649-55. (5) J Comp Neurol. 2014 Feb. 15;522:499-513. (6) Neurology. 2014;82:435-442.

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

Injuries from falls can result in a loss of independence. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Taking a tumble can result in broken bones and torn ligaments. These can be serious for older patients, where the consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability and a decline in physical and social activities (1). Ultimately, a fall can lead to loss of independence (2).

What can increase your fall risk?

Of course, there are environmental factors, like slippery or uneven surfaces. Other contributing factors to personal fall risk include age and medication use. Some medications, like antihypertensive medications, which are used to treat high blood pressure, and psychotropic medications, which are used to treat anxiety, depression and insomnia, are of particular concern. Chronic diseases can also contribute.

Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (3).

What are some simple ways to reduce your fall risk?

It is most important to exercise. This means exercises that involve balance, strength, movement, flexibility and endurance, all of which play significant roles in fall prevention (4). The good news is that many of these can be done inside with no equipment or with items found around the home. We will look more closely at the research.

Nonslip shoes are a big help and, during the winter months, footwear that prevents sliding on ice, such as slip-on ice cleats that fit over your shoes.

In the home, inexpensive changes, like securing area rugs, removing tripping hazards, installing grab-bars to your bathroom showers and tubs, and adding motion-activated nightlights can also make a difference.

And, of course, pay attention when you’re walking. Resist the urge to text or read from your mobile device while you’re moving around. A recently published study of young, healthy adults found that texting while walking affected their gait stability and postural balance when they were exposed to a slip hazard (5).

How does medication put you at risk?

There are several medications that heighten fall risk. Psychotropic drugs top the list, but what other drugs might have an impact? A well-designed study showed an increase in fall risk in those who were taking high blood pressure medication (6). Those on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase.

These medications can reduce significantly the risks of cardiovascular disease and events, so physicians need to consider the risk-benefit ratio in older patients before stopping a medication. We also should consider whether lifestyle modifications, which play a significant role in treating this disease, can reverse your need for medication (7).

How much does exercise reduce fall risk?

A meta-analysis showed that exercise significantly reduced the risk of a fall (8). It led to a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in falls that required medical attention. Even more impressive was a 61 percent reduction in fracture risk.

Remember, the lower the fracture risk, the more likely you are to remain physically independent. The author summarized that exercise not only helps to prevent falls but also fall injuries. Unfortunately, those who have fallen before, even without injury, often develop a fear that leads them to limit their activities. This leads to a dangerous cycle of reduced balance and increased gait disorders, ultimately resulting in an increased fall risk (9).

What types of exercise are best?

Any consistent exercise program that improves balance, flexibility, and muscle tone and includes core strengthening can help improve your balance. Among those that have been studied, tai chi, yoga and aquatic exercise have all been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial showed that those who did an aquatic exercise program had a significant improvement in the risk of falls (10). The goal of the aquatic exercise was to improve balance, strength and mobility. Results showed a reduction in the overall number of falls and a 44 percent decline in the number of exercising patients who fell during the six-month trial, with no change in the control group.

If you don’t have a pool available, tai chi, which requires no equipment, was also shown to reduce both fall risk and fear of falling in older adults (11).

Another pilot study used modified chair yoga classes with a small assisted-living population (12). Participants were those over 65 who had experienced a recent fall and had a resulting fear of falling. While the intention was to assess exercise safety, researchers found that participants had less reliance on assistive devices and three of the 16 participants were able to eliminate their use of mobility assistance devices.

Our best line of defense against fall risk is prevention with exercise and reducing slipping opportunities. In addition, if you are 65 and older, or if you have arthritis and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before you consider changing your blood pressure medications, review your risk-to-benefit ratio with your physician.


(1) MMWR. 2014; 63(17):379-383. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) JAMA. 1995;273(17):1348. (4) Cochrane Database Syst Rev. 2012;9:CD007146. (5) Heliyon. 2023 Aug; 9(8): e18366. (6) JAMA Intern Med. 2014 Apr;174(4):588-595. (7) JAMA Intern Med. 2014;174(4):577-587. (8) BMJ. 2013;347:f6234. (9) Age Ageing. 1997 May;26(3):189-193. (10) Menopause. 2013;20(10):1012-1019. (11) Mater Sociomed. 2018 Mar; 30(1): 38–42. (12) Int J Yoga. 2012 Jul-Dec; 5(2): 146–150.

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

It’s difficult to meet vitamin D needs with sunlight. Pixabay photo

By David Dunaief, M.D.

Dr. David Dunaief

This weekend, we’ll all “Spring forward” to Daylight Saving Time. While we’ll lose an hour of sleep on Sunday, the trade will be more hours of sunshine each day.

If you are like many in the Northeast, this is good news for your vitamin D3 levels. In practice, though, it’s still difficult to get enough sun exposure without putting yourself at higher risk for skin cancer.

There is no question that, if you have low levels of vitamin D, replacing it is important. Previous studies have shown that it may be effective in a wide swath of chronic diseases, both in prevention and as part of a treatment regimen. However, many questions remain.

Many of us receive food-sourced vitamin D from fortified packaged foods, where vitamin D3 has been added. This is because sun exposure does not address all of our vitamin D needs. For example, in a study of Hawaiians, a subset of the study population who had more than 20 hours of sun exposure without sunscreen per week, some participants still had low vitamin D3 values (1).

There is no consensus on the ideal blood level for vitamin D. For adults, the Institute of Medicine recommends between 20 and 50 ng/ml, and The Endocrine Society recommends at least 30 ng/ml.

Does body fat affect Vitamin D absorption?

An analysis of data from the VITAL trial, a large-scale vitamin D and Omega-3 trial, found that those with BMIs of less than 25 kg/m2 had significant health benefits from supplementation versus placebo (2). These included 24 percent lower cancer incidence, 42 percent lower cancer mortality, and 22 percent lower incidence of autoimmune disease. Those with higher BMIs showed none of these benefits.

Does vitamin D increase cardiovascular health?

Several observational studies have shown benefits of vitamin D supplements with cardiovascular disease. The Framingham Offspring Study showed that patients with deficient levels were at increased risk of cardiovascular disease (3).

However, a small randomized controlled trial (RCT) questioned the cardioprotective effects of vitamin D (4). This study of postmenopausal women, using biomarkers such as endothelial function, inflammation or vascular stiffness, showed no difference between vitamin D treatment and placebo. The authors concluded there is no reason to give vitamin D for prevention of cardiovascular disease.

The vitamin D dose given to the treatment group was 2,500 IUs. Some of the weaknesses of the study were a very short duration and small study size, so the results were not conclusive.

How does vitamin D affect mortality risk?

In a meta-analysis of a group of eight studies, vitamin D with calcium reduced the mortality rate in the elderly, whereas vitamin D alone did not (5). The difference between the groups was statistically important, but clinically small: nine percent reduction with vitamin D plus calcium and seven percent with vitamin D alone.

One of the weaknesses of this analysis was that vitamin D in two of the studies was given in large amounts of 300,000 to 500,000 IUs once a year, rather than taken daily. This has different effects.

Does vitamin D help you lose weight?

There is moderately good news on the weight front. the Study of Osteoporotic Fractures found that vitamin D plays a role in reducing the amount of weight gain in women 65 years and older whose blood levels are more than 30 ng/ml (6).

This association held true at baseline and after 4.5 years of observation. If the women dropped below 30 ng/ml in this time period, they were more likely to gain more weight, and they gained less if they kept levels above the target. There were 4,659 participants in the study. Unfortunately, sufficient vitamin D did not result in weight loss.

USPSTF recommendations and fracture risk

The U.S. Preventive Services Task Force recommends against giving “healthy” postmenopausal women vitamin D, calcium or the combination of vitamin D3 400 IUs plus calcium 1,000 mg to prevent fractures, and it found inadequate evidence of fracture prevention at higher levels (7). The supplement combination does not seem to reduce fractures, but it does increase the risk of kidney stones.

When should you supplement your vitamin D3?

It is important to supplement to optimal levels, especially since most of us living in the Northeast have insufficient to deficient levels. While vitamin D may not be a cure-all, it might play a role with many disorders. But it is also important not to raise your blood levels too high (8). The range that I tell my patients to target is between 32 and 50 ng/ml, depending on their health circumstances.


(1) J Endocrinology & Metabolism. 2007 Jun;92(6):2130-2135. (2) JAMA Netw Open. 2023 Published online Jan 2023. (3) Circulation. 2008 Jan 29;117(4):503-511. (4) PLoS One. 2012;7(5):e36617. (5) J Women’s Health (Larchmt). 2012 Jun 25. (6) J Clin Endocrinol Metabol. May 17, 2012 online. (7) JAMA. 2018;319(15):1592-1599. (8) Am J Lifestyle Med. 2021 Jul-Aug; 15(4): 397–401.

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

Even modest exercise can affect your genes. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Last week, I wrote that we should not rely on exercise for weight loss. Exercise is still important, though. It can alter how our genes express themselves and improve our outcomes with diseases and other health issues, such as diabetes, kidney stones, osteoarthritis, cardiovascular disease and breast, colorectal and endometrial cancers (1).

Despite all the positives, it can be difficult to motivate yourself to exercise. However, there are some simple ways to motivate yourself during exercise. One study showed that those who repeated positive mantras to themselves during exercise were able to persist for longer periods (2).

Why is this so important? Because we are too sedentary, and this is the time of the year when we are especially so. According to data from the 2015-2018 Behavioral Risk Factor Surveillance System, the Northeast had among the highest levels of physical inactivity in the U.S., at 25.6 percent of the population (3).

Does exercise alter your genes?

While it may not change our genes, exercise may change how our genes express themselves.

One study’s results showed that thousands upon thousands of genes in fat cells were affected when participants exercised for six months (4). During the study, sedentary men exercised twice a week at a one-hour spin class. According to the researchers, this affected genes that are involved in storing fat and in risk for subsequent diabetes and obesity development. The participants also improved other important health metrics, including their cholesterol, blood-pressure, fat percent and, later, their waist circumferences.

The effect identified on the fat cells is referred to as epigenetics, where lifestyle modifications ultimately lead to changes in gene expression, turning them on and off. This has been shown with dietary changes, but this is one of the first studies to show that exercise also has significant impacts on our genes. It took only six months to see these numerous gene changes with modest amounts of cardiovascular exercise.

Want more encouragement? Another study showed considerable gene changes in muscle cells after one workout on a stationary bike (5). Yet another introduced six weeks of endurance exercise to healthy, but sedentary, young men and identified an abundance of genetic changes to skeletal muscle, which has broad impacts on physical and cognitive health (6).

Can you treat cardiovascular disease with exercise?

What if we could forgo medications for cardiovascular disease by exercising? One meta-analysis examined 57 studies that involved drugs and exercise. It showed similar benefits in mortality with secondary prevention of coronary heart disease with statins and exercise (7). So, in patients who already have heart disease, both statins and exercise reduce the risk of mortality by similar amounts. The same study also showed that for those with pre-diabetes, it didn’t matter whether they took metformin or exercised – they had the same effect.

While these results are exciting, don’t change your medication without consulting your physician.

Does exercise help with kidney stones?

Anyone who has tried to pass a kidney stone knows it can be excruciating. Most treatments involve taking pain medication and fluids and just waiting for the stone to pass. Truly, the best way to treat kidney stones is to prevent them.

In the Women’s Health Initiative Observational Study, exercise reduced the risk of kidney stones by as much as 31 percent (8). Even better, the intensity of exercise did not change its beneficial effect. What mattered more was exercise quantity. One hour of jogging or three hours of walking got the top results; however, lesser amounts of exercise also saw substantial reductions. This study involved 84,000 postmenopausal women, the population most likely to suffer from kidney stones.

Does sexual activity count as exercise?

We have heard that sex is a form of exercise, but is this a myth or is there actual evidence? According to research, this may be true. In a study, researchers found that young, healthy couples exert 6 METs — metabolic energy, or the amount of oxygen consumed per kilogram per minute — during sexual activity (9).

How does this compare to other activities? We exert about 1 MET while sitting and 8.5 METs while jogging. In terms of energy used, sexual activity can be qualified as moderate activity. Men and women burned almost half as many calories with sex as with jogging, burning a mean of 85 calories over about 25 minutes. Who says exercise can’t be fun?

Movement and exercise not only help you feel better, they may also influence your genes’ expression. In certain circumstances, they may be as powerful as medications in preventing some diseases.


(1) JAMA. 2009;301(19):2024. (2) Med Sci Sports Exerc. 2013 Oct 10. (3) cdc.gov. (4) PLoS Genet. 2013 Jun;9(6):e1003572. (5) Cell Metab. 2012 Mar 7;15(3):405-11. (6) Mol Metab. 2021 Nov;53:101290. (7) BMJ. 2013; 347. (8) JASN. 2013;24(3):p 487-497. (9) PLoS One 8(10): e79342.

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

Exercise without dietary changes may not help you lose weight. METRO photo
Exercise without dietary changes may not help you lose weight

By David Dunaief

Dr. David Dunaief

We’re just past the point on the calendar when those who committed to exercising more in the new year are likely to have fallen off their resolutions. If you’re still following through, congratulations!

Exercise has benefits for a wide range of medical conditions, from depression, insomnia, fatigue and balance to cognitive decline, chronic kidney disease, diabetes, cardiovascular disease and osteoporosis.

Will it help you lose weight, though? While gym membership ads emphasize this in January, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. It may, however, be helpful with weight maintenance.

Ultimately, it may be more important to examine what you are eating than to succumb to the rationalization that you can eat without care and work it off later.

Will exercise help you lose weight?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will tip the scale in favor of weight loss. The more you burn, the more you will lose. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise. This is a moderately intense pace.

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 3.5 pounds, and at 12 months, participants lost about 3.75 pounds.

Does exercise play a role in weight maintenance?

Exercise may help with weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year (6).

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects roughly one in seven U.S. adults, as a simple example of exercise’s impact on disease (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (8). There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact, and the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

There are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

By all means, exercise, but to lose weight, also focus on consuming nutrient-dense foods instead of calorie-dense foods that you may not be able to exercise away.


(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

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