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Medical Compass

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 Increasing tomato sauce consumption is a simple way to                      decrease your prostate cancer risk

By David Dunaief, M.D.

Dr. David Dunaief

Welcome to “Movember,” a month dedicated to raising money to fund awareness and research initiatives focused on men’s health (1). An initiative of the Movember Foundation, its efforts have funded 1,320 men’s health projects globally, with focuses on mental health, suicide prevention, testicular and prostate cancer.

Its prostate cancer initiatives focus on early detection, treatment options, and quality of life considerations for different treatments. I’d like to add prevention options to the conversation. Regardless of your family history, you can reduce your risk of prostate cancer with some simple lifestyle changes.

How does obesity affect prostate cancer risk?

Obesity may slightly decrease the risk of nonaggressive prostate cancer; however, it may also increase your risk of aggressive disease (2). Because larger prostates make biopsies less effective, the study’s authors attribute a lower incidence of nonaggressive cancer to the possibility that it is more difficult to detect it in obese men. Ultimately, those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Does consuming animal fat affect your risk?

There appears to be a direct effect between the amount of animal fat we consume and the incidence of prostate cancer. In the Health Professionals Follow-up Study, those who consumed the highest amount of animal fat had a 63 percent increased risk of advanced or metastatic prostate cancer, compared to those who consumed the least (3).

Also, in this study, red meat contributed to an even greater, approximately 2.5-fold, increased risk of advanced disease. If you continue to eat red meat, reduce your frequency as much as possible, targeting once a month or quarter.

In another large, prospective observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (4).

Should you cook your tomatoes?

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not demonstrated the same beneficial effects. It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit. Tomatoes need to be cooked to release lycopene (5). 

As part of this larger study, 32 patients with localized prostate cancer consumed 30 mg of lycopene per day via tomato sauce-based dishes over a three-week period before a radical prostatectomy. Key cancer indicators improved, and tissue tested before and after the intervention showed dramatic improvements in DNA damage in leukocyte and prostate tissue (6). 

In a prospective study involving 47,365 men who were followed for 12 years, prostate cancer risk was reduced by 16 percent with higher lycopene intake from a variety of sources (7). When the authors looked at tomato sauce alone, they saw a 23 percent risk reduction when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. This was a statistically significant reduction in risk with a very modest amount of tomato sauce.

Unfortunately, many brands of prepared tomato sauce are loaded with salt, which has its own health risks. I recommend to patients that they either make their own sauce or purchase prepared sauce made with low sodium or no salt.

Do cruciferous vegetables help?

While results among studies vary, they all agree: consuming vegetables, especially cruciferous vegetables, helps reduce prostate cancer risk.

In a case-control study, participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (8). What’s even more impressive is the effect was twice that of tomato sauce, while the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

A separate study of 1,338 patients with prostate cancer in a larger cancer screening trial concluded that, while vegetable and fruit consumption did not appear to lower outright prostate cancer risk, increased consumption of cruciferous vegetables — specifically broccoli and cauliflower — did reduce the risk of aggressive prostate cancer, particularly of more serious stage 3 and 4 tumors (9). These results were seen with consumption of just one or more servings of each per week, when compared to less than one per month.

What about PSA screening?

In a retrospective analysis of 128 U.S. Veteran’s Health Administration facilities, those where Prostate-specific antigen (PSA) screening was less frequent found higher rates of metastatic prostate cancer (10). During the study period from 2005 to 2019, researchers found an inverse relationship between PSA screening rates and metastatic prostate cancer. When screening rates decreased, rates of metastatic cancer increased five years later, while in facilities where screening rates increased, metastatic cancer rates decreased. 

While the study authors caution about extending these findings to the general population, they do suggest they could help inform conversations between men and their physicians about the value of PSA screening. 

When it comes to preventing prostate cancer and improving prostate cancer outcomes, lifestyle modifications, including making dietary changes, can reduce your risk significantly.

References:

(1) www.movember.com. (2) Epidemiol Rev. 2007;29:88. (3) J Natl Cancer Inst. 1993;85(19):1571. (4) Am J Epidemiol. 2009;170(9):1165. (5) Exp Biol Med (Maywood). 2002; 227:914-919. (6) J Natl Cancer Inst. 2002;94(5):391. (7) Exp Biol Med (Maywood). 2002 Nov;227(10):886-93. (8) J Natl Cancer Inst. 2000;92(1):61. (9) J Natl Cancer Inst. 2007;99(15):1200-1209. (10) JAMA Oncol. 2022 Dec 1;8(12):1747-1755.

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.

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Image from METRO
Increasing fiber consumption is crucial

By David Dunaief

Dr. David Dunaief

According to the Centers for Disease Control and Prevention, about 6.7 percent of U.S. adults over the age of 19 have coronary artery disease (CAD), the most common type of heart disease (1). Annually in the U.S., there are 805,000 heart attacks. Of these, 200,000 occur in those who’ve already had a first heart attack.

Among the biggest contributors to heart disease risk are high blood pressure, high cholesterol, and smoking. In addition, if you have diabetes or are overweight or obese, your risk increases significantly. In addition, lifestyle factors contribute to your risk; poor diet, lack of physical activity and high alcohol consumption are among the most significant contributors.

This is where we can dramatically reduce the occurrence of CAD. Evidence continues to highlight lifestyle changes, including diet, as the most important factors in preventing heart disease. Key changes that pack a wallop include the consumption of chocolate, legumes, nuts, fiber and omega-3 polyunsaturated fatty acids (PUFAs).

Chocolate – really?

Preliminary evidence shows that two pieces of chocolate a week may decrease the risk of a heart attack by 37 percent, compared to those who consume less (2). The benefit may be attributed to micronutrients referred to as flavanols. 

However, the authors warned against the idea that more is better. High fat and sugar content and chocolate’s caloric density may have detrimental effects when consumed at much higher levels. There is a fine line between potential benefit and harm. 

I usually recommend that patients have one to two squares — about one-fifth to two-fifths of an ounce — of high-cocoa-content dark chocolate daily. Aim for chocolate labeled with 80 percent cocoa content.

Alternatively, you can get the benefits without the fat and sugar by adding unsweetened, non-Dutched cocoa powder to a fruit and vegetable smoothie.

Who says prevention has to be painful?

Will increasing dietary fiber help?

We can significantly reduce our risk of heart disease if we increase our consumption of fiber to reach recommended levels. Good sources of fiber are fruits and vegetables eaten with edible skin or peel, beans and lentils, and whole grains.

Fiber has a dose-response relationship to reducing risk. In other words, the more fiber you eat, the greater your risk reduction. In a meta-analysis of 10 studies, results showed that for every 10-gram increase in fiber, there was a corresponding 14 percent reduction in the risk of a cardiovascular event and a 27 percent reduction in the risk of heart disease mortality (3). The authors analyzed data that included over 90,000 men and 200,000 women.

According to a 2021 analysis of National Health and Nutrition Examination Survey (NHANES) data from 2013 to 2018, only 5 percent of men and 9 percent of women get the recommended daily amount of fiber (4). The average American consumes about 16 grams per day of fiber (5).

So, how much is “enough”? The Academy of Nutrition and Dietetics recommends 14 grams of fiber for each 1,000 calories consumed, or roughly 25 grams for women and 38 grams for men (6).

Legumes have an outsized effect

In a prospective (forward-looking) cohort study, the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, legumes reduced the risk of coronary heart disease by a significant 22 percent (7). Those who consumed four or more servings per week saw this effect when compared to those who consumed less than one serving per week. The legumes used in this study included beans, peas and peanuts. There were over 9,500 men and women involved, and the study spanned 19 years of follow-up.

I recommend that patients consume at least one to two servings a day. Imagine the impact that could have, compared to the modest four servings per week used to reach statistical significance in this study.

Focus on healthy nuts

In a study with over 45,000 men, there were significant reductions in CAD with omega-3 polyunsaturated fatty acids (PUFAs). Both plant-based and seafood-based omega-3s showed these effects (8). Good sources of omega-3s from plant-based sources include nuts, such as walnuts, and ground flaxseed. Of course, be cautious about consuming too many nuts, since they’re also calorically dense.

Your ultimate goal should be to become “heart attack proof,” a term used by Dr. Sanjay Gupta and reinforced by Dr. Dean Ornish. While even modest dietary changes can significantly reduce your risk, the more significant the lifestyle changes you make, the closer you will come to achieving this goal.

References:

(1) cdc.gov. (2) BMJ 2011; 343:d4488. (3) Arch Intern Med. 2004 Feb 23;164(4):370-376. (4) nutrition.org (5) NHANES 2009-2010 Data Brief No. 12. Sep 2014. (6) eatright.org. (7) Arch Intern Med. 2001 Nov 26;161(21):2573-2578. (8) Circulation. 2005 Jan 18;111(2):157-164.

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.

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METRO image
Getting an annual eye exam is crucial

By David Dunaief, M.D.

Dr. David Dunaief

If you have diabetes, you are at high risk of vascular complications that can be life-altering. Among these are macrovascular complications, like coronary artery disease and stroke, and microvascular effects, such as diabetic nephropathy and retinopathy.

Here, we will talk about diabetic retinopathy (DR), the number one cause of blindness among U.S. adults, ages 20 to 74 years old (1). Diabetic retinopathy is when the blood vessels that feed the light-sensitive tissue at the back of your eye are damaged, and it can progress to blurred vision and blindness.

As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (2). Why does this matter? Because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.

Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by fluid accumulating in the macula (3). An oval spot in the central portion of the retina, the macula is sensitive to light. When fluid builds up from leaking blood vessels, it can cause significant vision loss.

Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (2).

In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (4). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.

Unfortunately, the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse the damage.

What are treatment options for Diabetic Macular Edema?

While DME has traditionally been treated with lasers, injections of anti-VEGF medications may be more effective. These eye injections work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (5). The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were equally effective in treating DME (6). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).

Do diabetes treatments reduce risk of Diabetic Macular Edema?

You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (7). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings for other significant issues.

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

This contradicts a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (8). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).

What does this ultimately mean? Both studies had weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (9). There are additional studies underway to clarify these results.

Can glucose control and diet improve outcomes?

The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (10). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, an inference can be made: a nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (11, 12).

If you have diabetes, the best way to avoid diabetic retinopathy and DME is to maintain good control of your sugars. Also, it is imperative that you have a yearly eye exam by an ophthalmologist, so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.

References:

(1) cdc.gov. (2) www.aao.org/ppp. (3) www.uptodate.com. (4) JAMA Ophthalmol. 2014;132:168-173. (5) Community Eye Health. 2014; 27(87): 44–46. (6) ASRS. Presented 2014 Aug. 11. (7) Arch Intern Med. 2012;172:1005-1011. (8) Arch Ophthalmol. 2010 March;128:312-318. (9) Arch Intern Med. 2012;172:1011-1013. (10) www.nei.nih.gov. (11) OJPM. 2012;2:364-371. (12) Am J Clin Nutr. 2009;89:1588S-1596S.

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

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Long-term PPI use increases serious risks. Stock photo

By David Dunaief, M.D,

Dr. David Dunaief

Reflux is common after a large meal. This is when stomach contents flow backward up the esophagus. It occurs because the valve between the stomach and the esophagus, the lower esophageal sphincter, relaxes for no apparent reason. Many incidences of reflux are normal, especially after a meal, and don’t require medical treatment (1).

However, gastroesophageal reflux disease (GERD) is a more serious disorder. It can have long-term health effects, including erosion or scarring of the esophagus, ulcers, and increased cancer risk. Researchers estimate it affects as much as 28 percent of the U.S. adult population (2). No wonder pharmaceutical firms line drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers, such as spicy, salty, or fried foods, peppermint, and chocolate, can also play a role.

One study showed that both smoking and salt consumption increased GERD risk significantly, with increases of 70 percent in people who smoked or who used table salt regularly (4). Let’s examine available treatments and ways to reduce your risk.

What medical options can help with GERD?

The most common and effective medications for treating GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Concerns about long-term usage effects and overprescribing have led to calls among pharmacists to take an active role in educating patients about their risks – along with educating patients about the need to take them before eating for them to work (7).

What are PPI risks?

Side effects after years of use can include increased risk of bone fractures and calcium malabsorption; Clostridium difficile (C. difficile), a serious bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (8).

The FDA has amplified its warnings about the increased risk of C. difficile, which must be treated with antibiotics. Unfortunately, it only responds to a few antibiotics, and that number is dwindling. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (9).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (10). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician.

Before you stop taking PPIs, consult your physician. Rebound hyperacidity can result from stopping abruptly.

What non-medical options can improve GERD?

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (11). 

Fiber and exercise. The study that quantified the increased risks of smoking and salt also found that fiber and exercise both had the opposite effect, reducing GERD risk (4). An analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (12).

Manage weight. In one study, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (13). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with a “normal” body mass index.

Avoid late night eating. One of the most powerful modifications we can make to avoid GERD is among the simplest. A study showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more before bedtime (14).

While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References:

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014; 63(6):871-80. (3) niddk.nih.gov. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) US Pharm. 2019:44(12):25-31. (8) World J Gastroenterol. 2009;15(38):4794–4798. (9) FDA.gov. (10) Linus Pauling Institute; lpi.oregonstate.edu. (11) Arch Intern Med. 2006;166:965-971. (12) JWatch Gastro. Feb. 16, 2005. (13) Gastroenterology 2006 Mar; 130:639-649. (14) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

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

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'I have seen very good results when treating patients who have eczema with dietary changes.- Dr. David Dunaief METRO photo
New treatments are evolving

By David Dunaief, M.D.

Dr. David Dunaief

If you have eczema, you’re familiar with its symptoms, which can include rashes, itching, pain and redness. What may not be as clear are its causes and potential implications.

Eczema is a chronic inflammatory process, and it’s likely caused by a combination of genetics and lifestyle choices (1).

While there is no cure, some treatments can ease symptoms and reduce flare-ups. These range from over-the-counter creams and lotions, antihistamines for itchiness, prescription steroid creams, oral steroids, and injectable biologics. Some sufferers use phototherapy for severe cases, but there’s not a lot of research suggesting this is effective. Interestingly, diet may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

How does diet affect eczema?

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (2).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet of those who were allergic, according to IgE testing, eczema improved significantly (3).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes many patients who suffer from some level of eczema. For example, a young adult had eczema mostly on his extremities. When we first met, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin improved significantly.

Do supplements help reduce eczema symptoms?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective. There are also some important concerns about them.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (4).

The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (5).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Are biologics a good alternative?

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (6). There are two currently approved by the FDA, dupilumab and tralokinumab.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like other monoclonal antibodies, they work by interfering with parts of your immune system. They suppress messengers of the white blood cells, called interleukins. This leaves a door open for side effects, like serious infections.

Does eczema affect bone health?

Several studies have examined the relationship between eczema and broken bones. One observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and a 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (7).

If you have both fatigue or insomnia in combination with eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that corticosteroids used in treatment could be one reason, in addition to chronic inflammation, which may also contribute to bone loss risk. 

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (8). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life. Supplements may not be the solution, at least not borage oil nor evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroids because of their long-term side effects. Diet adjustments appear to be very effective, at least at the anecdotal level.

References:

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) Allergy. 2010 Jun 1;65(6):758-765. (3) J Am Acad Dermatol. 2004;50(3):391-404. (4) Cochrane Database Syst Rev. 2013;4:CD004416. (5) mayoclinic.org (9) Medscape.com. (6) JAMA Dermatol. 2015;151(1):33-41. (7) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (8) nationaleczema.org.

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.

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Quality years are achievable. METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

On Sunday, former U.S. President Jimmy Carter celebrated his 99th birthday. While he is currently in hospice care, most of his last decade, he has been healthy and active.

Living into your 90s is becoming more common. According to the National Institutes of Health, those in the U.S. who were more than 90 years old increased by 2.5 times over a 30-year period from 1980 to 2010 (1). This group is among what researchers refer to as the “oldest-old,” which includes those aged 85 and older.

What do they all have in common, other than age? According to one study, they tend to have fewer chronic medical conditions or diseases. Because of this, they tend to have greater physical functioning and mental acuity, along with a better quality of life (2).

In a study of centenarians, genetics played a significant role. Characteristics of this group were that they tended to be healthy and then die rapidly, without prolonged suffering (3). In other words, they grew old “gracefully,” staying mobile and mentally alert.

Factors that predict one’s ability to reach this exclusive club may involve both genetics and lifestyle choices. Let’s look at the research.

How important is exercise?

We’re repeatedly nudged to exercise. Why? Results of one study with over 55,000 participants from ages 18 to 100 showed that five-to-ten minutes of daily running, regardless of the pace, can significantly impact our life span by decreasing cardiovascular and all-cause mortality (4).

Amazingly, even if participants ran fewer than six miles a week at a pace slower than 10-minute miles, and even if they ran only one to two days a week, there was still a decrease in mortality compared to nonrunners. Those who ran for this very limited amount of time and modest pace potentially added three years to their life span.

An accompanying editorial to this study noted that more than 50 percent of people in the United States do not meet the current recommendation of at least 30 minutes of moderate exercise per day (5).

A study presented at the European Society of Cardiology Congress in 2022 found that those 85 and older reduced the risk of all-cause mortality 40 percent by walking just 60 minutes a week at a pace that qualified as physical activity, not even exercise (6).

Does reducing animal protein consumption help?

A long-standing dietary paradigm has been that we need to eat sufficient animal protein. However, many are questioning the value of this, especially as it relates to longevity.

In an observational study of 7,000 participants from ages 50 to 65, results show that those who ate a high-protein diet with greater than 20 percent of their calories from protein had a had a 75 percent increase in overall mortality, a four-times increased risk of cancer mortality, and a four-times increased risk of dying from diabetes during the following 18 years (7). 

However, this did not hold true if the protein source was plants. In fact, a high-protein plant diet may reduce the risks, not increase them. The reason, according to the authors, is that animal protein may increase insulin growth factor-1 and growth hormones that have detrimental effects on the body.

The Adventists Health Study 2 trial reinforced these findings. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein once a week or less had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (8). This was an observational trial with over 73,000 participants and a median age of 57 years old.

What effect does systemic inflammation have?

In the Whitehall II study, a specific marker for inflammation was measured, interleukin-6. The study showed that higher levels did not bode well for participants’ healthy longevity (9). If participants had elevated IL-6 (>2.0 ng/L) at both baseline and at the end of the 10-year follow-up period, their probability of healthy aging decreased by almost half.

The good news is that inflammation can be improved significantly with lifestyle changes.

The takeaway from this study is that IL-6 is a relatively common biomarker for inflammation. It can be measured with a simple blood test offered by most major laboratories. This study involved 3,044 participants over the age of 35 who did not have a stroke, heart attack or cancer at the beginning of the study.

The bottom line is that, although genetics are important for longevity, so too are lifestyle choices. A small amount of exercise and consuming more plant protein than animal protein can contribute to a substantial increase in healthy life span. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Your doctor can test to see if you have an elevated IL-6. If you do, lifestyle modifications may be able to reduce these levels.

References:

(1) nia.nih.gov. (2) J Am Geriatr Soc. 2009;57:432-440. (3) Future of Genomic Medicine (FoGM) VII. Presented March 7, 2014. (4) J Am Coll Cardiol. 2014;64:472-481. (5) J Am Coll Cardiol. 2014;64:482-484. (6) European Society of Cardiology Congress, Aug. 28, 2022. (7) Cell Metab. 2014;19:407-417. (8) JAMA Intern Med. 2013;173:1230-1238. (9) CMAJ. 2013;185:E763-E770.

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.

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METRO photo

By David Dunaief, M.D.

Dr. David Dunaief

Obesity is an ongoing struggle for many in the United States. If you, like many, are struggling to shed those extra “COVID-era pounds,” I’m sure you can relate.

Obesity is defined as a BMI (body mass index) of >30 kg/m2. More importantly, obesity can also be defined by excess body fat, which is more important than BMI.

While the medical community has known for some time that excess body fat contributes to poor health outcomes, it became especially visible during the first few rounds of COVID-19.

In the U.S., poor COVID-19 outcomes have been associated with obesity. In a study involving 5700 COVID-19 patients hospitalized in the New York City area, 41.7 percent were obese. The most common comorbidities contributing to hospitalization were obesity, high blood pressure and diabetes (1). In other words, obesity contributed to more severe symptoms.

In a study in China, results showed that those who were overweight were 86 percent more likely to have severe COVID-19 pneumonia, and that percentage increases to 142 percent when patients qualify as obese (2).

And though age is a risk factor for COVID-19, among those younger than 60 and obese, there is a two-times increased risk of being admitted to the hospital, according to a 3,615-patient study at NYU Langone Health (3).

While these studies were on early variants of COVID, the attention and wide-ranging research provide us with an interesting series of studies in how excess weight might impact progression of other acute respiratory diseases.

Why is the risk for severe COVID-19 higher with obesity? 

According to the prevailing theory, obesity may interfere with mechanical aspects of breathing, thus increasing airway resistance and making gas in exchange more difficult in the lung. It may also impede lung volume by exerting pressure on the lungs and may involve weaker muscles necessary for respiration (4).

Why does excess fat affect health outcomes? 

First, some who have elevated BMI may not have a significant amount of fat; they may have more innate muscle, instead. These people are not necessarily athletes. It’s just how they were genetically put together.

More than 25 percent of my patient population is “solidly built,” which means they have greater muscle mass, but also too much excess fat. Visceral fat, which is wrapped around the organs, including the lungs, is the most important.

Fat cells have adipokines, specific cell communicators that “talk” with other fat cells but also other systems such as the brain, immune system, muscles, and liver. Adipokines can be mediators of both inflammation and insulin resistance (5). It’s the inflammation among obese patients that could be the exacerbating factor for hospitalizations and severe illness, according to the author of a 4000-patient COVID-19 study (6). 

How can you reduce inflammation and lose excess fat?

In a randomized controlled trial with 75 participants comparing a plant-based diet to a control diet, there was a greater than 14 lbs. weight reduction and roughly 10 lbs. fat reduction over a 14-week period (7). Of the weight lost, about 70 percent was excess fat. Remember, excess body fat, through adipokines, may be inflammatory and increase the risk of severe disease. 

Weight reduction with a plant-based approach may be results of dietary fiber increases and dietary fat reductions with plant-based diets, according to Physician’s Committee for Responsible Medicine (PCRM) (8). You also want a diet that has been shown to reduce inflammation.

We published a study involving 16 patients from my clinical practice in 2020. It shows that those who ate a whole food plant-based LIFE (low inflammatory foods everyday) diet over a seven-day period had a significant decrease in inflammation measured by hsCRP (high sensitivity c-reactive protein). This occurred in those who completely changed their diets to the LIFE diet, but also occurred in those who simply added a daily greens-and-fruit-based smoothie to their existing diet (9).

In my practice, I have seen many patients lose substantial amounts of weight over a short period. More importantly, they also lost body fat. For instance, a 70-year-old male lost 19 lbs. of weight and 12 lbs. of body fat over a six-week period. His inflammation, which was very high to start, dropped substantially to the border of optimal levels. This patient and many others have seen tandem reductions in both weight and inflammation. To boot, this was a cardiac patient whose cardiologist had considered a stent, but later said he did not need it after reducing his inflammation.

The most recent health crisis shone a spotlight on the importance of losing excess fat. It’s not just about COVID-19 or other respiratory disease severity, although those are concerning. It’s also about excess fat’s significant known contributions to many other chronic diseases, like cardiovascular disease, high blood pressure, and high cholesterol.

References:

(1) JAMA. online April 22, 2020. (2) Clin Med (Lond). 2020 Jul; 20(4): e109–e113. (3) Clin Infect Dis. 2020 Jul 28;71(15):896-897. (4) Chron. Respir. Dis. 5, 233–242 (2008). (5) Front Endocrinol (Lausanne). 2013; 4:71. (6) MedRxiv.com. (7) Nutr Diabetes. 2018; 8: 58. (8) Inter Journal of Disease Reversal and Prevention 2019;1:1. (9) Amer J Lifestyle Med. 2022;16(6):753-764.

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.

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Diet may have a significant impact on heart failure risk and outcomes

By David Dunaief, M.D.

Dr. David Dunaief

Unlike a heart attack, which is acute, heart failure develops slowly and may take years to become symptomatic. Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. According to the American Heart Association, over six million Americans are affected, and the numbers are projected to increase significantly by 2030 (1).

There are two types of heart failure, systolic and diastolic. The basic difference is that the ejection fraction, the output of blood with each contraction of the left ventricle of the heart, is more or less preserved in diastolic HF, while it can be significantly reduced in systolic HF.

Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue. Each of these can impact quality of life significantly.

Major lifestyle risk factors for heart failure include obesity; smoking; poor diet, including consuming too much sodium; being sedentary; and drinking alcohol excessively. Conditions that increase your risk include diabetes, coronary artery disease and high blood pressure.

Typically, heart failure is treated with blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. We are going to look at how diet and iron levels can affect heart failure outcomes.

Can diet improve heart failure?

If we look beyond the usual risk factors mentioned above, oxidative stress may play an important role as a contributor to HF.

In a population-based, prospective study, the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (2). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. According to the authors, the antioxidants were derived mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for the majority of the effect.

What makes this study so impressive is that it is the first of its kind to investigate antioxidants from the diet and their impacts on heart failure prevention.

This was a large study, involving 33,713 women, with good duration — follow-up was 11.3 years. There are limitations to this study, because it is observational, and the population involved only women. Still, the results are very exciting, and it is unlikely there is a downside to applying this approach to the population at large.

More recently, the REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. 

The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (3). Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF.

Does iron supplementation improve heart failure outcomes?

An observational study that followed 753 heart failure patients for almost two years showed that iron deficiency without anemia increased the risk of mortality in heart failure patients by 42 percent (4).

In this study, iron deficiency was defined as a ferritin level less than 100 μg/L (the storage of iron) or, alternately, transferrin saturation less than 20 percent (the transport of iron) with a ferritin level in the range 100–299 μg/L.

The authors conclude that iron deficiency is potentially more predictive of clinical outcomes than anemia, contributes to the severity of HF and is common in these patients. However, studies of oral iron supplementation has not been shown to improve results, while intravenous supplementation has been shown to reduce hospitalizations and mortality (5).

These studies suggest that we should try to prevent heart failure through dietary changes, including high levels of antioxidants, because it is not easy to reverse the disease. Those with HF should have their ferritin and iron levels checked, because these can be addressed with medical supervision.

References:

(1) Circulation. 2020;141:e139–e596. (2) Am J Med. 2013 Jun:126(6):494-500. (3) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045. (4) Am Heart J. 2013;165(4):575-582. (5) Eur J Heart Fail. 2018;20(1):125–133.

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.

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Flu, RSV and COVID-19 are especially tough on those with impaired lung function

By David Dunaief, M.D.

Dr. David Dunaief

Our experiences over the past several years with COVID-19 have increased our awareness of how chronic ailments can make us more vulnerable to the consequences of acute diseases circulating in our communities.

For those with chronic obstructive lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma, as well as those who smoke and vape, the consequences of the flu, RSV and COVID-19 are especially severe.

The good news is that we can do a lot to improve our lung function by exercising, eating a plant-based diet with a focus on fruits and vegetables, expanding lung capacity with an incentive spirometer, and quitting smoking and vaping, which damage the lungs (1). Studies suggest that everyone will benefit from these simple techniques, not only people with compromised lungs.

Do antioxidants improve asthma?

In a randomized controlled trial, results show that, after 14 days, asthma patients who ate a high-antioxidant diet had greater lung function than those who ate a low-antioxidant diet (2). They also had lower inflammation at 14 weeks. Inflammation was measured using a c-reactive protein (CRP) biomarker. Participants in the low-antioxidant group were over two-times more likely to have an asthma exacerbation.

The good news is that there was only a small difference in behavior between the high- and low-antioxidant groups. The high-antioxidant group had a modest five servings of vegetables and two servings of fruit daily, while the low-antioxidant group ate no more than two servings of vegetables and one serving of fruit daily. Using carotenoid supplementation in place of antioxidant foods did not affect inflammation. The authors concluded that an increase in carotenoids from diet has a clinically significant impact on asthma in a very short period.

Can increasing fiber lower COPD risk?

Several studies demonstrate that higher consumption of fiber from plants decreases the risk of COPD in smokers and ex-smokers.

In one study of men, results showed that higher fiber intake was associated with significant 48 percent reductions in COPD incidence in smokers and 38 percent incidence reductions in ex-smokers (3). The high-fiber group ate at least 36.8 grams per day, compared to the low-fiber group, which ate less than 23.7 grams per day. Fiber sources were fruits, vegetables and whole grain, essentially a whole foods plant-based diet. The “high-fiber” group was still below the American Dietetic Association’s recommended intake of 14 grams per 1,000 calories each day.

In another study, this time with women, participants who consumed at least 2.5 serving of fruit per day, compared to those who consumed less than 0.8 servings per day, experienced a highly significant 37 percent decreased risk of COPD (4).

The highlighted fruits shown to reduce COPD risk in both men and women included apples, bananas, and pears.

What devices can help improve lung function?

An incentive spirometer is a device that helps expand the lungs when you inhale through a tube and cause a ball (or multiple balls) to rise in a tube. This inhalation opens the alveoli and may help you breathe better.

Incentive spirometry has been used for patients with pneumonia, those who have had chest or abdominal surgery and those with asthma or COPD, but it has also been useful for healthy participants (5). A small study showed that those who trained with an incentive spirometer for two weeks increased their lung function and respiratory motion. Participants were 10 non-smoking healthy adults who were instructed to take five sets of five deep breaths twice a day, totaling 50 deep breaths per day. Incentive spirometers are inexpensive and easily accessible.

In another small, two-month study of 27 patients with COPD, the incentive spirometer improved blood gasses, such as partial pressure carbon dioxide and oxygen, in COPD patients with exacerbation (6). The authors concluded that it may improve quality of life for COPD patients.  

How does exercise help improve lung function?

Exercise can have a direct impact on lung function. In a study involving healthy women aged 65 years and older, results showed that 20 minutes of high-intensity exercise three times a day improved FEV1 and FVC, both indicators of lung function, in just 12 weeks (7). Participants began with a 15-minute warm-up, then 20 minutes of high-intensity exercise on a treadmill, followed by 15 minutes of cool-down with stretching.

Note that you don’t need special equipment to do aerobic exercise. You can walk up steps or steep hills in your neighborhood, do jumping jacks, or even dance around your living room. Whatever you choose, you want to increase your heart rate and expand your lungs. If this is new for you, consult a physician and start slowly. You’ll find that your stamina improves quickly when you do it consistently.

We all should be working to strengthen our lungs. This three-pronged approach of lifestyle modifications — diet, exercise and incentive spirometer — can help.

References:

(1) Public Health Rep. 2011 Mar-Apr; 126(2): 158-159. (2) Am J Clin Nutr. 2012 Sep;96(3):534-43. (3) Epidemiology Mar 2018;29(2):254-260. (4) Int J Epidemiol Dec 1 2018;47(6);1897-1909. (5) Ann Rehabil Med. Jun 2015;39(3):360-365. (6) Respirology. Jun 2005;10(3):349-53. (7) J Phys Ther Sci. Aug 2017;29(8):1454-1457.

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.

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Getting a good night's rest helps keep your mind and body healthy. METRO image
Sleep apnea may increase your risks of cardiovascular disease and cancer

By David Dunaief, M.D.

Dr. David Dunaief

Our physical and mental wellbeing depends on getting quality, restful sleep; however, many of us struggle to achieve this. For those with obstructive sleep apnea (OSA), quality sleep is particularly elusive.

Sleep apnea is an abnormal pause in breathing that occurs at least five times an hour while sleeping. It can have an array of causes, the most common of which is airway obstruction. Some estimates suggest that about 30 million people suffer from sleep apnea in the United States (1).

OSA diagnoses are classified as either mild, moderate or severe. It’s estimated that roughly 80 percent of moderate and severe OSA sufferers are undiagnosed.

After family history, most risk factors for OSA are modifiable. They include chronic nasal congestion, excess weight or obesity, alcohol use and smoking (2).

Symptoms of OSA include daytime fatigue, loud snoring, breathing cessation observed by another, impaired concentration, and morning headaches. While these are significant quality of life issues, OSA is also associated with an array of more serious health consequences, such as cardiovascular disease, high blood pressure and depression.

Fortunately, we have an arsenal of treatment options, including continuous positive airway pressure (CPAP) devices; oral appliances; lifestyle modifications, such as diet, exercise, smoking cessation and reduced alcohol intake; and some medications.

How does sleep apnea affect cardiovascular disease risk?

In an observational study of 1,116 women over a six-year duration, the risk of cardiovascular mortality increased in a linear fashion with the severity of OSA (3). For those with mild-to-moderate untreated sleep apnea, there was a 60 percent increased risk of death; for those in the severe group, this risk jumped considerably to 250 percent. However, the good news is that treating patients with CPAP considerably decreased their risk by 81 percent for mild-to-moderate patients and 45 percent for severe OSA patients.

Another observational study of 1,500 men with a 10-year follow-up showed similar risks of cardiovascular disease with sleep apnea and benefits from CPAP treatment (4). The authors concluded that severe sleep apnea increases the risk of nonfatal and fatal cardiovascular events, and CPAP was effective in curbing these occurrences.

In a third study, this time involving the elderly, OSA increased the risk of cardiovascular death in mild-to-moderate patients and in those with severe OSA by 38 and 125 percent, respectively (5). But, as in the previous studies, CPAP decreased the risk in both groups significantly. In the elderly, an increased risk of falls, cognitive decline and difficult-to-control high blood pressure may be signs of OSA.

Does OSA increase your risk of cancer?

In sleep apnea patients under age 65, a study showed an increased risk of cancer (6). The greater the percentage of time patients spend in hypoxia (low oxygen) at night, the greater the risk of cancer. The authors believe that intermittent low levels of oxygen, caused by the many frequent short bouts of breathing cessation, may be responsible for the development of tumors and their subsequent growth.

Does OSA affect male sexual function?

Erectile dysfunction (ED) may also be associated with OSA and, like other outcomes, CPAP may decrease this incidence. This was demonstrated in a small study involving 92 men with ED (7). The surprising aspects of this study were that, at baseline, the participants were overweight, not obese, on average and were only 45 years old. 

In those with mild OSA, the CPAP had a beneficial effect in over half of the men. For those with moderate and severe OSA, the effect was still significant, though not as robust, at 29 and 27 percent, respectively.

An array of other studies on the association between OSA and ED have varying results, depending on the age and existing health challenges of the participants. Some study authors have postulated that other underlying health problems may be the cause in some patient populations.

Can diet help address OSA?

For some of my patients, their goal is to discontinue their CPAP. Diet may be an alternative to CPAP, or it may be used in combination with CPAP to improve results.

In a small study of those with moderate-to-severe OSA levels, a low-energy diet showed positive results. A low-energy diet implies a low-calorie approach, such as a diet that is plant-based and nutrient-rich. It makes sense, since this can help with weight loss. In the study, almost 50 percent of those who followed this type of diet were able to discontinue CPAP (8). The results endured for at least one year.

If you think you are suffering from sleep apnea, you should be evaluated at a sleep lab and then follow up with your doctor. Don’t let obstructive sleep apnea cause severe complications, possibly robbing you of more than sleep. There are many effective treatments.

References:

(1) sleepapnea.org. (2) JAMA. 2004;291(16):2013. (3) Ann Intern Med. 2012 Jan 17;156(2):115-122. (4) Lancet. 2005 Mar 19-25;365(9464):1046-1053. (5) Am J Respir Crit Care Med. 2012;186(9):909-916. (6) Am J Respir Crit Care Med. 2012 Nov. 15. (7) Sleep. 2012;35:A0574. (8) BMJ. 2011;342:d3017.

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.

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