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Medical Compass

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By David Dunaief, M.D.

Dr. David Dunaief

We need help, and we need it fast. Not just for COVID-19, but also for diabetes, for the combination of the two is much worse than either disease alone. Type 2 diabetes can have devastating effects that can potentially result in patients dying prematurely from cardiovascular complications (1). COVID-19 symptoms can range from asymptomatic to severe or result in death.

Now combine diabetes with COVID-19 and you are at much higher risk of severe viral symptoms that require hospitalization and ICU admission. According to the CDC, about one-third ICU patients infected with COVID-19 have diabetes (2). 

Keeping patients out of the hospital

We know containment is critical to control COVID-19, but it’s equally important to get ahead of the mitigation of symptoms curve; we need to control the chronic diseases that exacerbate the virus’s severity. And Type 2 diabetes is one of the largest contributors. 

We can treat and reverse diabetes by empowering patients with lifestyle changes, especially diet. This is such an issue that the Mexican Deputy Minister of Health recently alluded to the fact that poor diet over at least the last 4 decades has resulted in more diabetes and obesity making people much more susceptible to COVID-19 and progressing to severe COVID-19 (3). 

It is tempting while staying at home for most of the day to want reach for comfort foods. Don’t do it. In fact, take the opposite approach and improve your diet. A whole food plant-based (WFPB) diet has been shown time and time again to prevent, treat and reverse diabetes potentially resulting in patients getting off their drugs and achieving levels that are considered normoglycemic, or non-diabetic. 

Let’s look at the evidence. 

Treating and reversing diabetes

Drugs help treat glucose, or sugar levels, and help reduce the risk of microvascular diseases such as diabetic retinopathy (eye disease causing blindness); nephropathy (kidney disease); and peripheral neuropathy, which can result in amputation. A few medications can even reduce macrovascular risk, or cardiovascular disease. Still, diet is still the best tool we have for reversing diabetes overall, with only beneficial side effects.

With COVID-19, those whose glucose is not under control are at highest risk of severe disease that results in a progression from hospitalization to ICU and the need for a ventilator to increased mortality risk. High sugars may have negative impacts on the white blood cells, which makes patients more susceptible to infection from viruses (4).

Medications’ impact

Diabetes medication alone can help control sugars, but it can’t reverse diabetes. In fact, studies with medication alone may actually increase the risk of death from polypharmacy, or too many medications. In the ACCORD trial, patients were put on an average of four diabetes medications. Researchers stopped the trial early after 3.5 years, because of a 22 percent increased rate of mortality (5). Patients did not reach their HbA1C (a three-month sugar reading) target of under 6.0 percent, because the increased death rate occurred at around 6.5. This was a large randomized controlled clinical trial with 10,251 patients, a mean age of 62.2 years, and mean HbA1C of 8.1 at baseline. 

Reversing Type 2 diabetes: plant-based dietary approach

On the other hand, studies with a WFPB diet, have shown significant reduction in sugars and potential reversal of diabetes. These include a small retrospective study and small randomized clinical trial comparing a WFPB diet to the American Diabetes’ (ADA) recommended diet. 

In a small retrospective study, the results showed a reduction of HbA1C from 8.2, which was a similar baseline as with the ACCORD trial, to 5.8 (6). Remember, the goal of the ACCORD trial was to get patients below a HbA1C of 6.0. These results occurred over a mean of seven months. In addition, patients were able to stop all of their diabetes medications and reduce their total number of medications from four to one.  The side effect was better health with a significant reduction in high blood pressure to normal levels, as well.

The weakness of this study was that it was retrospective (looking backward in time), only had 13 patients, and there was no control arm. However, it suggests that this type of diet is powerful to reduce and reverse type 2 diabetes. The foods used in the nutrient-dense WFPB diet included a non-starchy vegetable-rich approach, with an emphasis on dark green leafy vegetables, whole fruits, beans, and limiting grains, especially refined grains, and limiting starchy vegetables such as sweet potatoes, winter squashes, corn and pumpkin. 

In a larger study, results showed that a high fiber diet in patients with type 2 diabetes and hypertension significantly reduced HbA1C, fasting glucose, systolic (top number) blood pressure, branchial-ankle pulse wave velocity, serum cholesterol and waist-to-hip ratio, ultimately reducing the risk of cardiovascular disease (7). The participants were considered to be having high fiber if they increased their consumption 20-25 percent above recommended daily allowances. The fiber came from foods, not supplements, including vegetables, fruits, beans and whole grains. There were 200 participants over a six-month duration. 

A third study, which was a randomized controlled trial comparing the 2003 American Diabetes Association (ADA) diet to a low-fat vegan diet showed that a low-fat vegan diet significantly reduced the HbA1C compared to the 2003 ADA diet in a 74-week study (8). There were 99 type 2 diabetes patients in the study. A “side effect” of the low-fat vegan diet was that it also significantly reduced cholesterol. 

Preventing diabetes

There have been numerous studies demonstrating that a WFPB diet reduces the risk of diabetes. One of the best was the Adventist Health Study 2 (9). The results showed that a vegan diet reduced the risk of type 2 diabetes by 49 percent. This study is interesting because the different groups were very similar and it showed that small changes could have a big impact. Semi-vegetarians, pesco-vegetarians, and lacto-ovo vegetarians all had a reduced risk of diabetes compared to plant-focused non-vegetarians, but not as much as vegans. 

In a more recent study, results showed a 30 percent reduction in the risk of type 2 diabetes for those who ate a predominantly whole food plant-based diet including fruits, vegetables and whole grains (10). Participants were still eating some animal protein daily. This was over a 2-to-28 year period in a metanalysis involving nine observational trials.

In conclusion, the best way to reduce your risk of severe COVID-19 is to control and reverse chronic disease. Type 2 diabetes is one of the most common chronic diseases that may contribute to getting COVID-19 and progressing to a severe form. A nutrient-dense WFPB diet has been shown to potentially reverse type 2 diabetes. While you are mostly housebound, empower yourself by taking action to reduce your risk of getting COVID-19 and especially the severe disease. We have the tools: it starts with what you put on your plate.

References:

(1) Lancet 389(10085):2239–2251. (2) CDC.gov. (3) Reuters.com April 4, 2020. (4) Medscape.com March 18, 2020. (5) NEJM 2008;358:2545-2559. (6) OJPM 2012;2(3):364-371. (7) ACC Middle East Conference 2019 Presentation. (8) Am J Clin Nutr.2009 May; 89(5): 1588S–1596S. (9) Diabetes Care. 2009;32:791–796. (10) JAMA Int. Med. Online July 22, 2019.

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

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Sticking to a plant-rich diet that can reduce high blood pressure. Stock photo
Call to arms to reverse high blood pressure, once and for all

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension (high blood pressure) and COVID-19 are intertwined. Those who have hypertension are more susceptible to COVID-19 and are more likely to get a severe form and experience complications from the virus. A study done in China captured the statistics: of 1099 patients infected, 15 percent had hypertension, and of those with severe cases, 23.7 percent had hypertension (1). Ultimately, those with hypertension are at higher risk, but we don’t at this point understand the specifics of why.

Even before the COVID-19 pandemic, a recent study showed that the number of deaths from hypertension had increased a whopping 26 percent overall from 2007 to 2017 (2). 

What about medications to blunt the association? There is a THEORY, not a study, that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may be harmful by increasing ACE2 in the lungs, which is a receptor that COVID-19 binds to; however, there is also a case for these medications having benefits (3). Do not stop or change your hypertension medications without talking to your doctor. Remember, this is just a theory, and theories are very dangerous; we don’t have research to support them, by definition (4).

I view this as a call to arms to control and, even more importantly, treat and reverse hypertension. Presently, only 54 percent of hypertension patients are controlled with medication (5). 

Potential to control and reverse hypertension through diet

We have the capability to treat and reverse hypertension with lifestyle modifications, including diet, exercise, sleep and stress management. We are going to focus on diet.

A whole foods plant-based diet (WFPBD) that is dark green leafy vegetable-rich has been shown to help prevent, control and possibly reverse hypertension. I call this the LIFE diet, which stands for Low Inflammatory Foods Everyday. The most researched type of WFPBD is the DASH (dietary approach to stopping hypertension) diet, which emphasizes fruits, vegetables, grains and reductions in saturated fats and total fat. DASH was the first randomized control trial to show that a predominantly whole food plant-based approach reduces blood pressure (6).

Why does diet have an effect? There are several factors, including inflammation; electrolytes, specifically sodium and potassium; and phytochemicals (plant nutrients and fiber content).

Why is inflammation so important?

Inflammation is a culprit in most chronic diseases, including hypertension. It also plays a crucial role in the severity of COVID-19. Those who take a turn for the worse in COVID-19 have high inflammation. On the news, an ER doctor noted that while COVID-19 patients may come in stable, they need to be watched carefully; in 3-24 hours, they could show high inflammation and fluid in their lungs and need to be on a ventilator.

There are several studies that show a direct relationship between high sensitivity C-reactive protein, one of the most well-studied biomarkers for inflammation, and hypertension in both men and women (7)(8). In the Physicians Health Study, those men who had high hsCRP (>3 mg/L) and hypertension had a 40 percent increased risk of stroke compared to those without hypertension and with hsCRP <1, which is optimal. Not to leave women out, the CARDIA study found that premenopausal women with elevated hsCRP were significantly more likely to have hypertension.

How can we decrease inflammation?

Anti-inflammatory drugs, including NSAIDS like ibuprofen, may suppress the immune system and make patients more susceptible to COVID-19. They also worsen hypertension and may increase the risk for cardiovascular events, such as a heart attack. In fact, prescription NSAIDS carry an FDA black box warning about this dangerous side effect. Anti-inflammatory drugs should not be the “go-to” solution.

Fortunately, a WFPBD is associated with reduction in inflammation, specifically hsCRP. We recently published a study showing that the LIFE diet has an inverse relationship between blood levels of beta carotene, a phytonutrient, and hsCRP (9). As you increase the intake of dark green leafy vegetables, the higher the beta carotene and the lower the hsCRP. There was a 75 percent reduction in inflammation with those that increased their beta carotene over the normal level compared to those who were non-adherent. The DASH diet also emphasizes an increased intake of vegetables.

There are studies to suggest that, as we lower animal protein intake, we are able to better reduce blood pressure. In the EPIC study, those who at who reduced animal protein to none had the biggest impact on blood pressure. This study compared meat-eaters, fish-eaters, vegetarians and vegans (10). 

Electrolytes – sodium and potassium

The optimal approach for these electrolytes is to have a sodium to potassium ratio that is less than one. For most, this means consuming less sodium and more potassium (11). The American Heart Association emphasizes low sodium, less than 1500 mg of sodium per day and higher potassium intake (12). 

What I find in my practice is that blood levels that are south of 140 mmol/L are better and that the bottom of the range is ideal; the range is between 135-145 mmol/L. This way, whether you are sodium-sensitive or not, you can either help control blood pressure or rule it out as a factor. Potassium should be 4.5 (units) or higher. These electrolytes should come from vegetables, especially dark green leafy vegetables, which have a natural balance of potassium and sodium. Other good sources of potassium are beans and nuts.

Ultimately, the power is in your hands. By changing your diet to one that is more plant-based and vegetable-rich, you can reduce inflammation, strengthen your immune system, possibly reduce or even get off anti-hypertension medications, reverse the trend of dying from hypertension, and reduce your susceptibility to severe COVID-19.

References:

(1) N Engl J Med. Online Feb 28, 2020. (2) J Am Coll Cardiol. Online March 19, 2020). (3) Nephron. Online Mar 23, 2020.) (4) Nature. Feb 2020, 579:270–273. (5) Circulation. 2016;133:e38–e360. (6) N Engl J Med. 1997 Apr 17; 336(16):1117-24. (7) JAMA.2015 Sep:4(9):e002073 (8) Menopause. 2016 Jun; 23(6):662. (9) AJLM Online. Dec. 21, 2019. (10) Oybkuc Gektg Bytr, 2002 Oct; 5(5):645-54. (11) Circulation Online. Oct 11 2017. (12) heart.org.

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

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By David Dunaief, M.D.

Dr. David Dunaief

COVID-19, a strain of the coronavirus, is now a pandemic. I have been barraged with questions from patients, neighbors and friends. They are right to be asking questions, because there is not enough information being circulated about how to protect yourself and your family. 

Key elements

The key weapons we have in this fight against COVID-19 are containment and mitigation. A lot has been shared about containment by the Centers for Disease Control. Containment is reducing the incidence of new cases to a goal of zero, thus flattening the prevalence curve so this virus is no longer infecting anyone. This requires social distancing, hand washing for at least 20 seconds, surface cleaning, and avoiding touching your eyes, nose and mouth (1). If you have not already, I encourage you to review the guidelines at www.cdc.gov/coronavirus.

There is less information being provided about how we can minimize the severity of the disease if we are infected. This is mitigation. Mitigation is about preparing ourselves, so we experience an asymptomatic or a mild form. 

Who is most at risk?

According to a study focusing on Wuhan, China findings, people most at risk are those who have chronic diseases, with high blood pressure, diabetes and heart disease being the three most common (2). Also at risk are those who are “older,” that is 60 years or older, for they are more likely to have weakened immune systems and increased inflammation.

Managing your immune response

Ultimately, the goal is to have a healthy, appropriate immune system response. If the immune system “under-responds,” the virus’s symptoms will be more severe. Another term for this is immunocompromised. 

If the immune system is overstimulated, your white blood cells are more likely to attack healthy tissue and cause further damage, exacerbating the situation. This sometimes happens after a heart attack, where the immune response is overzealous, targets healthy tissue and causes dysfunction in the heart. This process is called remodeling.

The goal is to create a healthy/strengthened immune system — not to boost and not to suppress the immune system. You want the “Goldilocks” of immune responses: not too little, not too much, but just right.

What can be done?

The best methodology here is to lean on what I call the four pillars of lifestyle modification: diet, exercise, stress management, and sleep.  

Diet. By implementing a nutrient-dense, whole food plant-based (WFPB) diet or, more specifically, what I call a “Low Inflammatory Foods Everyday (LIFE) diet,” you can rapidly improve or even reverse these chronic diseases, decrease inflammation and strengthen your immune system, which will decrease your chances of dying from the virus.

The Lancet study referenced above found that inflammation and a weakened immune system were central to determining how people will do on entering the hospital.

What I’ve found with the LIFE diet in my practice is that people have white blood cells that are on the low end of the scale, between 2.5-4.5, rather than in the middle or upper range of 6.0-10.8. Typically, my patients’ white blood cells when they get sick stay within the normal range of 3.4-10.8. In fact., I had a patient who recently got a cold virus: their white blood cells were 3.4 before they got sick, and they rose to only 7.8, well within the normal range. This resulted in a targeted response with recovery in a very short time period. 

For those with healthy immune systems, if they do get the coronavirus, their response will be more likely targeted instead of a disproportionately large response that starts killing the virus but also the healthy tissue in the lungs, leading to increased inflammation and fluid build-up in the lungs. Dr Fauci has warned this could potentially happen – what is called a cytokine storm – although the chances are very small. Ultimately, the immune system in these situations contributes to the problem, instead of helping.

So, what can you do to incorporate LIFE diet habits into your daily routine?

Focus on fresh and frozen fruits, vegetables and legumes. This is very important. With vegetables, the focus should be on dark green leafy vegetables, such as spinach, bok choy, kale, broccoli and cauliflower, as well as mushrooms. More is better. You cannot have too much. For fruits, apples have shown to play an important role in lung health, and all types of berries have high anti-inflammatory effects. 

WFPB diets ultimately help with inflammation and immune strengthening and also support reduced stress and better sleep. The reason for these effects may have to do with the microbiome, the microbes living in your gut, which are an important determinant of how your immune system functions. Seventy percent of your immune cells are in your gut.

You can test for inflammation by looking at both white blood cell count and high sensitivity CRP (hsCRP). Beta carotene levels in the blood are a way to measure nutrient levels. I recently published a study that showed there is an inverse relationship between beta carotene in the blood and inflammation measured through hsCRP. This showed a 75 percent reduction in inflammation with higher beta carotene levels achieved through a plant-rich diet focusing on dark green leafy vegetables.

Interestingly, you don’t seem to achieve the same reduction in inflammation from vitamins or plant-based powders as you do by eating actual fruits and vegetables and legumes.

Stress management and exercise. Please, don’t panic. When you stress, your body releases cortisol, or internal steroids, that actually weaken the immune system and increase your risk of serious infection. Techniques to reduce your stress include exercise, yoga and meditation.

Mild to moderate exercise can be effective, such as a walk or jog outdoors or up and down the steps of your home. Just because the gyms may be closed in your area does not mean you can’t get exercise. It is spring, let’s take advantage of the weather, which will also help with mood and stress.

You can also exercise your lungs using an incentive spirometer. My personal favorite is the Triflo II version, but there are many on the market. I recommend taking 10 breaths using the incentive spirometer twice a day. This can help expand your lungs and keep the aveoli healthy and open. Aveoli exchange oxygen and carbon dioxide molecules to and from the bloodstream.

Sleep. Exercise will also help with sleep, as will the LIFE diet. Getting enough quality sleep is important to strengthening the immune system. Quality, not quantity, is most crucial. 

What if you are infected?

If you are infected, supportive care is most critical: stay hydrated; focus on foods with fluids in them to help with this, like fruits, vegetables, and low-salt vegetable-based soups; and sleep.

Importantly, stay away from NSAIDS. These are mostly over-the-counter medications such as ibuprofen, naproxen and even aspirin, but can be prescriptions such as diclofenac. These suppress the immune system, thus making it more difficult for it to fight (3)(4). The mechanism of action for this suppression of the immune system is an anti-inflammatory effect that is different and detrimental, compared to the favorable anti-inflammatory effects of a WFPB diet such as the LIFE diet.

Instead, you want to reduce fever using acetaminophen, or Tylenol. This will not have any effects on inflammation, thus not interfering with the body’s immune system. If you can’t tolerate acetaminophen for fever, some alternatives may be elderflowers, catnip (which is a gentle choice for children), yarrow, white willow bark, echinacea, and lemon balm, although there is little data on their effectiveness.

Do not hesitate to go to the hospital if you have difficulty breathing, persistent pain or pressure in your chest, new confusion or an inability to get up, or bluish lips or face. These are signs of potentially severe and life-threatening COVID-19 symptoms.

To sum it all up, chronic diseases and not managing those four lifestyle pillars are risk factors for dying from COVID-19. You can improve or reverse your chronic diseases, as well as strengthen your immune system and reduce inflammation through a plant-rich dark green leafy vegetable diet like the LIFE diet

References:

(1) cdc.gov/coronavirus. (2) Lancet. Published online March 9, 2020. (3) Lung. 2017;195(2):201-8. (4) Chest. 2011;139(2):387-94

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

 

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Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Stock photo
Lifestyle plays an important role in reducing symptoms

By David Dunaief, M.D.

Dr. David Dunaief

According to estimates, 10 to 15 percent of the population suffers from irritable bowel syndrome (IBS) symptoms, although only five to seven percent have been diagnosed (1). The general perception is that IBS symptoms are somewhat vague. They include cramping, abdominal pain, bloating, constipation and diarrhea. 

Physicians use the Rome III criteria, an international effort to create scientific data to help diagnose and treat functional gastrointestinal disorders, plus a careful history and physical exam for diagnosis. 

What epitomizes IBS is the colonoscopy study, where IBS patients who underwent colonoscopy had diagnostic findings of nil. This tended to frustrate patients more, not reduce their worrying, as the study authors had hoped (2).

Rather, it plays into that idea that patients don’t have diagnostic signs, like in inflammatory bowel disease, yet their morbidity (sickness) has a profound effect on their quality of life. Socially, it is difficult and embarrassing to admit having IBS. Plus, with a potential psychosomatic component, it leaves patients wondering if it’s “all in their heads.”

So, what can be done to improve IBS? There are a number of possibilities to consider.

Mental state’s effect

The “brain-gut” connection is real. It refers to the direct connection between mental state, such as nervousness or anxiety, to gastrointestinal issues, and vice versa.

Mindfulness-based stress reduction was used in a small, but randomized, eight-week clinical trial with IBS (3). Those in the mindfulness group (treatment group) showed statistically significant results in decreased severity of symptoms compared to the control group, both immediately after training and three months post-therapy.

Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.

A preliminary study has suggested there may be a link between IBS and migraine and tension-type headaches. The study of 320 participants, 107 with migraine, 107 with IBS, 53 with episodic tension-type headaches (ETTH), and 53 healthy individuals, identified significant occurrence crossover among those with migraine, IBS and ETTH. Researchers also found that these three groups had at least one gene that was different from that of healthy participants. Their hope is that this information will lead to more robust studies that could result in new treatment options (4).

The role of gluten

In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo (68 percent vs. 40 percent, respectively).

These results were highly statistically significant (5). The authors concluded that nonceliac gluten intolerance may exist. Gluten sensitivity may be an important factor in the pathogenesis of a portion of IBS patients (6).

I suggest to my patients that they might want to start avoiding gluten and then add it back into their diets to see the results.

Fructose intolerance

Some IBS patients may suffer from fructose intolerance. In a prospective (forward-looking) study, IBS patients were tested for this with a breath test. The results showed a dose-dependent response. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.

The symptoms of fructose intolerance included flatus, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that avoidance of fructose may reduce symptoms in IBS patients (7).

According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (8). Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.

What is the role of lactose?

Another small study found that about one-quarter of patients with IBS also have lactose intolerance. Two things are at play here. One, it is very difficult to differentiate the symptoms of lactose intolerance from IBS. The other is that most IBS trials are small and there is a need for larger trials.

Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptomatology at both six weeks and five years when placed on a lactose-restrictive diet (9).

Though small, the trial results were statistical significant, which is impressive. Both the durability and the compliance were excellent, and visits to outpatient clinics were reduced by 75 percent. This demonstrates that it is most probably worthwhile to test patients for lactose intolerance who have IBS.

Do probiotics help?

Treatment with probiotics from a study that reviewed 42 trials shows that there may be a benefit to probiotics, although the endpoints were different in each trial. The good news is that most of the trials reached one of their endpoints (10).

Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.

All of the above gives IBS patients a sense of hope that there are options for treatments that involve modest lifestyle changes. I believe there needs to be a strong patient-doctor connection in order to choose the appropriate options that result in the greatest symptom reduction.

References:

(1) American College of Gastroenteroloy [GI.org]. (2) Gastrointest Endosc. 2005 Dec;62(6):892-899. (3) Am J Gastroenterol. 2011 Sep;106(9):1678-1688. (4) American Academy of Neurology 2016, Abstract 3367. (5) Am J Gastroenterol. 2011 Mar;106(3):508-514. (6) Am J Gastroenterol. 2011 Mar;106(3):516-518. (7) Am J Gastroenterol. 2003 June;98(6):1348-1353. (8) J Clin Gastroenterol. 2008 Mar;42(3):233-238. (9) Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944. (10) Aliment Pharmacol Ther. 2012 Feb;35(4):403-413.

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

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Taking Vitamin D may reduce the risk of developing Parkinson’s disease. Stock photo
Cumulative lifestyle changes can improve results

By David Dunaief

Dr. David Dunaief

According to the Parkinson’s Foundation, roughly 60,000 Americans are diagnosed with Parkinson’s disease (PD) each year, and approximately one million Americans are living with PD (1). PD is a neurodegenerative (the breakdown of brain neurons) disease with the resultant effect of a movement disorder.

Most notably, patients with the disease suffer from a collection of symptoms known by the mnemonic TRAP: tremors while resting, rigidity, akinesia/bradykinesia (inability/difficulty to move or slow movements) and postural instability or balance issues. It can also result in a masked face, one that has become expressionless, and potentially dementia, depending on the subtype. There are several different subtypes; the diffuse/malignant phenotype has the highest propensity toward cognitive decline (2).

The part of the brain most affected is the basal ganglia, and the prime culprit is dopamine deficiency that occurs in this brain region (3). Why not add back dopamine? Actually, this is the mainstay of medical treatment, but eventually the neurons themselves break down, and the medication becomes less effective.

There’s a lot we still don’t know about the causes of PD; however, risk factors may include head trauma, reduced vitamin D, milk intake, well water, being overweight, high levels of dietary iron and migraine with aura in middle age.

Is there hope? Yes, in the form of medications and deep brain stimulatory surgery, but also with lifestyle modifications. Lifestyle factors include iron, vitamin D and CoQ10. The research, unfortunately, is not conclusive, though it is intriguing.

Reducing iron in the brain

This heavy metal is potentially harmful for neurodegenerative diseases such as Alzheimer’s disease, macular degeneration, multiple sclerosis and, yes, Parkinson’s disease. The problem is that this heavy metal can cause oxidative damage.

In a small, yet well-designed, randomized controlled trial (RCT), researchers used a chelator to remove iron from the substantia nigra, a specific part of the brain where iron breakdown may be dysfunctional. An iron chelator is a drug that removes the iron. Here, deferiprone (DFP) was used at a modest dose of 30 mg/kg/d (4). This drug was mostly well-tolerated.

The chelator reduced the risk of disease progression significantly on the Unified Parkinson Disease Rating Scale (UPDRS) during the 12-month study. Participants who were treated sooner had lower levels of iron compared to a group that used the chelator six months later. A specialized MRI was used to measure levels of iron in the brain.

The iron chelator does not affect, nor should it affect, systemic levels of iron, only those in the brain specifically focused on the substantia nigra region. The chelator may work by preventing degradation of the dopamine-containing neurons. It also may be recommended to consume foods that contain less iron.

Does CoQ10 slow progression?

When we typically think of using CoQ10, a coenzyme found in over-the-counter supplements, it is to compensate for depletion from statin drugs or due to heart failure. Doses range from 100 to 300 mg. However, there is evidence that CoQ10 may be beneficial in Parkinson’s at much higher doses. In an RCT, results showed that those given 1,200 mg of CoQ10 daily reduced the progression of the disease significantly based on UPDRS changes, compared to the placebo group (5). Other doses of 300 and 600 mg showed trends toward benefit but were not significant. This was a 16-month trial in a small population of 80 patients. Though the results for other CoQ10 studies have been mixed, these results are encouraging. Plus, CoQ10 was well-tolerated at even the highest dose. Thus, there may be no downside to trying CoQ10 in those with PD.

Is Vitamin D part of the puzzle?

In a prospective (forward-looking) study, results show that vitamin D levels measured in the highest quartile reduced the risk of developing Parkinson’s disease by 65 percent, compared to the lowest quartile (6). This is quite impressive, especially since the highest quartile patients had vitamin D levels that were what we would qualify as insufficient, with blood levels of 20 ng/ml, while those in the lowest quartile had deficient blood levels of 10 ng/ml or less. There were over 3,000 patients involved in this study with an age range of 50 to 79.

While many times we are deficient in vitamin D and have a disease, replacing the vitamin does nothing to help the disease. Here, it does. Vitamin D may play dual roles of both reducing the risk of Parkinson’s disease and slowing its progression.

In an RCT, results showed that 1,200 IU of vitamin D taken daily, may have reduced the progression of Parkinson’s disease significantly on the UPDRS compared to a placebo over a 12-month duration (7). Also, this amount of vitamin D increased the blood levels by two times from 22.5 to 41.7 ng/ml. There were 121 patients involved in this study with a mean age of 72.

So, what have we learned? Though medication with dopamine agonists is the gold standard for the treatment of Parkinson’s disease, lifestyle modifications can have a significant impact on both prevention and treatment of this disease. Each lifestyle change in isolation may have modest effects, but cumulatively their impact could be significant. The most exciting part is that lifestyle modifications have the potential to slow the progression the disease and thus have a protective effect.

References:

(1) parkinsons.org. (2) JAMA Neurol. 2015;72:863-873. (3) uptodate.com. (4) Antioxid Redox Signal. 2014;10;21(2):195-210. (5) Arch Neurol. 2002;59(10):1541-1550. (6) Arch Neurol. 2010;67(7):808-811. (7) Am J Clin Nutr. 2013;97(5):1004-1013.

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

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By David Dunaief, M.D.

Dr. David Dunaief

COVID-19, a strain of the coronavirus, is now a pandemic. I have been barraged with questions from patients, neighbors and friends. They are right to be asking questions, because there is not enough information being circulated about how to protect yourself and your family. 

Key elements

The key weapons we have in this fight against COVID-19 are containment and mitigation. A lot has been shared about containment by the Centers for Disease Control. Containment is reducing the incidence of new cases to a goal of zero, thus flattening the prevalence curve so this virus is no longer infecting anyone. This requires social distancing, hand washing for at least 20 seconds, surface cleaning, and avoiding touching your eyes, nose and mouth (1). If you have not already, I encourage you to review the guidelines at www.cdc.gov/coronavirus.

There is less information being provided about how we can minimize the severity of the disease if we are infected. This is mitigation. Mitigation is about preparing ourselves, so we experience an asymptomatic or a mild form. 

Who is most at risk?

According to a study focusing on Wuhan, China findings, people most at risk are those who have chronic diseases, with high blood pressure, diabetes and heart disease being the three most common (2). Also at risk are those who are “older,” that is 60 years or older, for they are more likely to have weakened immune systems and increased inflammation.

Managing your immune response

Ultimately, the goal is to have a healthy, appropriate immune system response. If the immune system “under-responds,” the virus’s symptoms will be more severe. Another term for this is immunocompromised. 

If the immune system is overstimulated, your white blood cells are more likely to attack healthy tissue and cause further damage, exacerbating the situation. This sometimes happens after a heart attack, where the immune response is overzealous, targets healthy tissue and causes dysfunction in the heart. This process is called remodeling.

The goal is to create a healthy/strengthened immune system — not to boost and not to suppress the immune system. You want the “Goldilocks” of immune responses: not too little, not too much, but just right.

What can be done?

The best methodology here is to lean on what I call the four pillars of lifestyle modification: diet, exercise, stress management, and sleep.  

Diet. By implementing a nutrient-dense, whole food plant-based (WFPB) diet or, more specifically, what I call a “Low Inflammatory Foods Everyday (LIFE) diet,” you can rapidly improve or even reverse these chronic diseases, decrease inflammation and strengthen your immune system, which will decrease your chances of dying from the virus.

The Lancet study referenced above found that inflammation and a weakened immune system were central to determining how people will do on entering the hospital.

What I’ve found with the LIFE diet in my practice is that people have white blood cells that are on the low end of the scale, between 2.5-4.5, rather than in the middle or upper range of 6.0-10.8. Typically, my patients’ white blood cells when they get sick stay within the normal range of 3.4-10.8. In fact., I had a patient who recently got a cold virus: their white blood cells were 3.4 before they got sick, and they rose to only 7.8, well within the normal range. This resulted in a targeted response with recovery in a very short time period. 

For those with healthy immune systems, if they do get the coronavirus, their response will be more likely targeted instead of a disproportionately large response that starts killing the virus but also the healthy tissue in the lungs, leading to increased inflammation and fluid build-up in the lungs. Dr Fauci has warned this could potentially happen – what is called a cytokine storm – although the chances are very small. Ultimately, the immune system in these situations contributes to the problem, instead of helping.

So, what can you do to incorporate LIFE diet habits into your daily routine?

Focus on fresh and frozen fruits, vegetables and legumes. This is very important. With vegetables, the focus should be on dark green leafy vegetables, such as spinach, bok choy, kale, broccoli and cauliflower, as well as mushrooms. More is better. You cannot have too much. For fruits, apples have shown to play an important role in lung health, and all types of berries have high anti-inflammatory effects. 

WFPB diets ultimately help with inflammation and immune strengthening and also support reduced stress and better sleep. The reason for these effects may have to do with the microbiome, the microbes living in your gut, which are an important determinant of how your immune system functions. Seventy percent of your immune cells are in your gut.

You can test for inflammation by looking at both white blood cell count and high sensitivity CRP (hsCRP). Beta carotene levels in the blood are a way to measure nutrient levels. I recently published a study that showed there is an inverse relationship between beta carotene in the blood and inflammation measured through hsCRP. This showed a 75 percent reduction in inflammation with higher beta carotene levels achieved through a plant-rich diet focusing on dark green leafy vegetables.

Interestingly, you don’t seem to achieve the same reduction in inflammation from vitamins or plant-based powders as you do by eating actual fruits and vegetables and legumes.

Stress management and exercise. Please, don’t panic. When you stress, your body releases cortisol, or internal steroids, that actually weaken the immune system and increase your risk of serious infection. Techniques to reduce your stress include exercise, yoga and meditation.

Mild to moderate exercise can be effective, such as a walk or jog outdoors or up and down the steps of your home. Just because the gyms may be closed in your area does not mean you can’t get exercise. It is spring, let’s take advantage of the weather, which will also help with mood and stress.

You can also exercise your lungs using an incentive spirometer. My personal favorite is the Triflo II version, but there are many on the market. I recommend taking 10 breaths using the incentive spirometer twice a day. This can help expand your lungs and keep the aveoli healthy and open. Aveoli exchange oxygen and carbon dioxide molecules to and from the bloodstream.

Sleep. Exercise will also help with sleep, as will the LIFE diet. Getting enough quality sleep is important to strengthening the immune system. Quality, not quantity, is most crucial. 

What if you are infected?

If you are infected, supportive care is most critical: stay hydrated; focus on foods with fluids in them to help with this, like fruits, vegetables, and low-salt vegetable-based soups; and sleep.

Importantly, stay away from NSAIDS. These are mostly over-the-counter medications such as ibuprofen, naproxen and even aspirin, but can be prescriptions such as diclofenac. These suppress the immune system, thus making it more difficult for it to fight (3)(4). The mechanism of action for this suppression of the immune system is an anti-inflammatory effect that is different and detrimental, compared to the favorable anti-inflammatory effects of a WFPB diet such as the LIFE diet.

Instead, you want to reduce fever using acetaminophen, or Tylenol. This will not have any effects on inflammation, thus not interfering with the body’s immune system. If you can’t tolerate acetaminophen for fever, some alternatives may be elderflowers, catnip (which is a gentle choice for children), yarrow, white willow bark, echinacea, and lemon balm, although there is little data on their effectiveness.

Do not hesitate to go to the hospital if you have difficulty breathing, persistent pain or pressure in your chest, new confusion or an inability to get up, or bluish lips or face. These are signs of potentially severe and life-threatening COVID-19 symptoms.

To sum it all up, chronic diseases and not managing those four lifestyle pillars are risk factors for dying from COVID-19. You can improve or reverse your chronic diseases, as well as strengthen your immune system and reduce inflammation through a plant-rich dark green leafy vegetable diet like the LIFE diet

References:

(1) cdc.gov/coronavirus. (2) Lancet. Published online March 9, 2020. (3) Lung. 2017;195(2):201-8. (4) Chest. 2011;139(2):387-94

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

 

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Diet may also affect quality of life as we age

By David Dunaief, M.D.

Dr. David Dunaief

Here’s a stunning statistic: 60 percent of American adults have a chronic disease, with 40 percent of adults having more than one (1). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade at around 78.8 years old (2).

Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients, according to the Centers for Disease Control and Prevention (CDC). 

The truth is that many Americans are malnourished. How could that be, when so many are overweight or obese? We are not a developing country, where access to healthy food is more challenging. Still, malnourishment is common at all levels of socioeconomic class. The definition of malnourished is insufficient nutrition, which in the U.S. results from low levels of much-needed nutrients.

I regularly test patients’ carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. They are measurable and give the practitioner a sense of whether the patient may lack potentially disease-fighting nutrients. Testing is often covered if the patient is diagnosed with moderate malnutrition. Because the standard American diet is very low in nutrients, classifying a patient with moderate malnutrition can be appropriate. A high nutrient intake approach can rectify the situation and increase, among others, carotenoid levels.

High nutrient intake

A high nutrient intake is an approach that focuses on micronutrients, which literally means small nutrients, including antioxidants and phytochemicals -— plant nutrients. Micronutrients are bioactive compounds found mostly in foods and some supplements. While fiber is not considered a micronutrient, it also has significant disease modifying effects. Micronutrients interact with each other in synergistic ways, meaning the sum is greater than the parts. Diets that are plant-rich raise the levels of micronutrients considerably in patients.

In a 2017 study that included 73,700 men and women who were participants in the Nurses’ Health Study and the Health Professionals Follow-up Study, participants’ diets were rated over a 12-year period using three established dietary scores: the Alternate Healthy Eating Index–2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score (3).

A 20 percent increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17 percent, depending on whether two or three scoring methods were used. Participants who maintained a high-quality diet over a 12-year period reduced their risk of death by 9 to 14 percent than participants with consistently low diet scores over time. By contrast, worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12 percent. Not surprisingly, longer periods of healthy eating had a greater effect than shorter periods.

This study reinforces the findings of the Greek EPIC trial, a large prospective (forward-looking) cohort study, where the Mediterranean-type diet decreased mortality significantly – the better the compliance, the greater the effect (4). The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

Quality of life

Quality of life is also important, though. Let’s examine some studies that examine the impact of diet on diseases that may reduce our quality of life as we age.

A study showed olive oil reduces the risk of stroke by 41 percent (5). The authors attribute this effect at least partially to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. There are 120 calories per tablespoon of olive oil, all of them fat. If you eat too much, even of good fat, it defeats the purpose. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s. 

In a case-control (compare those with and without disease) study, high intake of antioxidants from food is associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), even when participants had a genetic predisposition for the disease (6). AMD is the leading cause of blindness in those 55 years or older. There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

Though many Americans are malnourished, nutrients that are effective and available can alter this predicament. Hopefully, with a focus on a high nutrient intake, we can re-ignite the pace of increased life expectancy and, on an individual level, improve our quality of life.

References:

(1) cdc.gov. (2) macrotrends.net. (3) N Engl J Med 2017; 377:143-153. (4) BMJ. 2009;338:b2337. (5) Neurology June 15, 2011. (6) Arch Ophthalmol. 2011;129(6):758-766.

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

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High sodium and hypertension can increase probability

By David Dunaief, M.D.

Kidney stones, or nephrolithiasis, can be asymptomatic (no symptoms at all) or may present with the classic symptoms of blood in the urine and colicky pain. Pain can be intermittent or constant, ranging from dull to extremely painful, described by some as being worse than giving birth, shot or burned. The pain may radiate from the kidneys to the bladder and even to the groin in males, depending on the obstruction (1). 

Lifetime risk of kidney stones is about 19 percent in men and 9 percent in women (2). Once you form one stone, your risk of another within five to seven years is approximately 50 percent.

Stones are usually diagnosed through clinical examination and abdominal x-rays and/or non-contrast CT scans.

Unfortunately, the first line treatment for passing kidney stones – at least small ones – involves supportive care. This means that patients are given pain medications and plenty of fluids until the stone(s) pass. Usually stones that are <4mm pass spontaneously. Location is an important factor as well, with stones closest to the opening of the urethra more likely to pass (3).

The good news is there are lifestyle changes that can reduce the risk of kidney stones. First, it is very important to stay hydrated, drinking plenty of fluids, especially if you have a history of stone formation (4).

Calcium supplementation’s impact

One of the easiest methods is to significantly reduce your intake of calcium supplements, including foods fortified with calcium. There are two types of stones, with calcium oxalate being the dominant one, occurring approximately 80 percent of the time (5). Calcium supplements increase the risk of kidney stones. When physicians started treating women for osteoporosis with calcium supplements, the rate of kidney stones increased by 37 percent (6). 

According to findings from the Nurses’ Health Study, those who consumed highest amount of supplemental calcium were 20 percent more likely to have kidney stones than those who consumed the lowest amount (7). It did not matter whether participants were taking calcium citrate or calcium carbonate supplements.

Interestingly, the same study found that calcium from dietary sources has the opposite effect, decreasing risk. Those participants who consumed the highest amount of dietary calcium had a 35 percent reduction in risk, compared to those who were in the lowest group. Calcium intake should not be too low, for that also increases kidney stone risk. However, the source of calcium is a key to preventing kidney stones. 

Sodium’s effect

It’s important to reduce sodium for many reasons, but this provides one more. Again, in the Nurses’ Health Study, participants who consumed 4.5 g sodium per day had a 30 percent higher risk of kidney stones than those who consumed 1.5 g per day (7). The reason is that increased sodium causes increased urinary excretion of calcium. When there is more calcium going through the kidneys, there is a higher chance of stones.

Animal protein

Animal protein also seems to play a role. In a five-year, randomized clinical trial, men who consumed small amounts of animal protein, approximately two ounces per day, and lower sodium were 51 percent less likely to experience a kidney stone than those who consumed low amounts of calcium (8). These were men who had a history of stone formation. The reason that animal protein may increase the risk of calcium oxalate stones more than vegetable protein is that its higher sulfur content produces more acid, which is neutralized by release of calcium from the bone (9).

Hypertension

Some medical conditions may increase the likelihood of stone formation. For example, in a cross-sectional study (a certain population during a specific period) with Italian men, those with high blood pressure had a two times greater risk of kidney stones than those who had a normal blood pressure (10). Amazingly, it did not matter if the patients were treated for their high blood pressure; the risk remained. This is just one more reason to treat the underlying cause of blood pressure, not the symptoms.

The most productive way to avoid the potentially excruciating experience of kidney stones is to make these relatively simple lifestyle changes. The more changes that you implement, the lower your risk of stones.

References:

(1) emedicine January 1, 2008. (2) kidney.org. (3) J Urol. 2006;175(2):575. (4) J Urol. 1996;155(3):839. (5) N Engl J Med. 2004;350(7):684. (6) Kidney Int 2003;63:1817–23. (7) Ann Intern Med. 1997;126(7):497-504. (8) N Engl J Med. 2002 Jan 10;346(2):77-84. (9) J Clin Endocrinol Metab. 1988;66(1):140. (10) BMJ. 1990;300(6734):1234. 

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

 

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Increasing fiber can reduce hemorrhoid inflammation

By David Dunaief

Dr. David Dunaief

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

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

There are two types of hemorrhoids: external, occurring outside the anus, and internal, occurring within the rectum. 

How do you treat external hemorrhoids? 

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

How do you treat internal hemorrhoids?

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

The first step for treating internal hemorrhoids is to add fiber through diet and supplementation. Study after study shows significant benefit. For instance, in a meta-analysis by the Cochrane Systems Data Review 2005, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, the daily incidence of bleeding was reduced dramatically (3).

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

Side effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgery) would be the next option.

How do you prevent hemorrhoids?

Adding more fiber to your diet will help prevent hemorrhoids.
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First, sitting on the toilet for long periods of time puts significant pressure on the veins in the rectum, potentially increasing the risk of inflammation. Though you may want private time to read, the bathroom is not the library. As soon as you have finished moving your bowels, it is important to get off the toilet.

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

Americans, on average, consume 16 g per day of fiber (5). The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25 to 38 g, depending on gender and age (6). I typically recommend at least 40 g. My wife and I try to eat only foods that contain a significant amount of fiber, and we get approximately 65 g per day. You may want to raise your fiber level gradually; if you do it too rapidly, be forewarned – side effects are potentially gas and bloating for the first week or two.

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

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

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-456. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-1507. (4) Dis Colon Rectum 2004 Aug;47(8):1364-1370. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1):80–85.

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

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Increasing fiber may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

Many patients say they have been diagnosed with diverticulitis, but this is a misnomer. Diverticulitis is actually a consequence of diverticular disease, or diverticulosis. Diverticulosis is one of the most common maladies that affects us as we age. For instance, 35 percent of U.S. 50-year-olds are affected and, for those over the age of 60, approximately 58 percent are affected (1). Many will never experience symptoms.

The good news is that it is potentially preventable through modest lifestyle changes. My goal in writing this article is twofold: to explain simple ways to reduce your risk, while also debunking a myth that is pervasive — that fiber, or more specifically nuts and seeds, exacerbates the disease.

What is diverticular disease? 

Diverticular disease is a weakening of the lumen, or wall of the colon, resulting in the formation of pouches or out-pocketing referred to as diverticula. The cause of diverticula may be attributable to pressure from constipation. Its mildest form, diverticulosis may be asymptomatic. 

Symptoms of diverticular disease may include fever and abdominal pain, predominantly in the left lower quadrant in Western countries, or the right lower quadrant in Asian countries. It may need to be treated with antibiotics.

Diverticulitis affects 10 to 25 percent of those with diverticulosis. Diverticulitis is inflammation and infection, which may lead to a perforation of the bowel wall. If a rupture occurs, emergency surgery may be required.

Unfortunately, the incidence of diverticulitis is growing. As of 2010, about 200,000 are hospitalized for acute diverticulitis each year, and roughly 70,000 are hospitalized for diverticular bleeding (2).

How to prevent diverticular disease

There are a number of modifiable risk factors, including fiber intake, weight and physical activity, to prevent diverticular disease.

In terms of fiber, there was a prospective (forward-looking) study published online in the British Medical Journal that extolled the value of fiber in reducing the risk of diverticular disease (3). This was part of the EPIC trial, involving over 47,000 people living in Scotland and England. The study showed a 31 percent reduction in risk in those who were vegetarian. 

But more intriguing, participants who had the highest fiber intake saw a 41 percent reduction in diverticular disease. Those participants in the highest fiber group consumed >25.5 grams per day for women and >26.1 grams per day for men, whereas those in the lowest group consumed less than 14 grams per day. Though the difference in fiber between the two groups was small, the reduction in risk was substantial. 

Another study, which analyzed data from the Million Women Study, a large-scale, population-based prospective UK study of middle-aged women, confirmed the correlation between fiber intake and diverticular disease, and further analyzed the impact of different sources of fiber (4). The authors’ findings were that reduction in the risk of diverticular disease was greatest with high intake of cereal and fruit fiber.

Most Americans get about 16 grams of fiber per day. The Institute of Medicine (IOM) recommends daily fiber intake for those <50 years old of 25-26 grams for women and 31-38 grams for men (5). Interestingly, their recommendations are lower for those who are over 50 years old.

Can you imagine what the effect is when people get at least 40 grams of fiber per day? This is what I recommend for my patients. Some foods that contain the most fiber include nuts, seeds, beans and legumes. In a study in 2009, specifically those men who consumed the most nuts and popcorn saw a protective effect from diverticulitis (6).

Obesity plays a role, as well. In the large, prospective male Health Professionals Follow-up Study, body mass index played a significant role, as did waist circumference (7). Those who were obese (BMI >30 kg/m²) had a 78 percent increased risk of diverticulitis and a greater than threefold increased risk of a diverticular bleed compared to those who had a BMI in the normal range of <21 kg/m². For those whose waist circumference was in the highest group, they had a 56 percent increase risk of diverticulitis and a 96 percent increase risk of diverticular bleed. Thus, obesity puts patients at a much higher risk of the complications of diverticulosis.

Physical activity is also important for reducing the risk of diverticular disease, although the exact mechanism is not yet understood. Regardless, the results are impressive. In a large prospective study, those with the greatest amount of exercise were 37 percent less likely to have diverticular disease compared to those with the least amount (8). Jogging and running seemed to have the most benefit. When the authors combined exercise with fiber intake, there was a dramatic 256 percent reduction in risk of this disease. 

Thus, preventing diverticular disease is based mostly on lifestyle modifications through diet and exercise.

References:

(1) www.niddk.nih.gov. (2) Clin Gastroenterol Hepatol. 2016; 14(1):96–103.e1. (3) BMJ. 2011; 343: d4131. (4) Gut. 2014 Sep; 63(9): 1450–1456. (5) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80–85. (6) AMA 2008; 300: 907-914. (7) Gastroenterology. 2009;136(1):115. (8) Gut. 1995;36(2):276.  

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

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