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Medical Compass

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Elimination diets may play a role in treating eczema. Stock photo
Broken bones are a common side effect of eczema

By David Dunaief, M.D.

Dr. David Dunaief

Eczema is a common problem for both children and adults. In the United States, more than 10 percent of the adult population is afflicted (1), with twice as many females as males affected (2).

Referred to more broadly as atopic dermatitis, its cause is unknown, but it is thought that nature and nurture are both at play (3). Eczema is a chronic inflammatory process that involves symptoms of pruritus (itching) pain, rashes and erythema (redness) (4). There are three different severities: mild, moderate and severe. Adults tend to have eczema in the moderate-to-severe range.

Treatments for eczema run the gamut from over-the-counter creams and lotions to prescription steroid creams to systemic (oral) steroids and, now, injectable biologics. Some use phototherapy for severe cases, but the research on phototherapy is scant. Antihistamines are sometimes used to treat the itchiness. Also, lifestyle modifications may play an important role, specifically diet. Two separate studies have shown an association between eczema and fracture, which we will investigate further. Let’s look at the evidence.

Eczema doesn’t just scratch the surface

Eczema may also be related to broken bones. In an observational study, results showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more disturbing 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (5). And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. One reason for increased fracture risk, the researchers postulate, is the use of corticosteroids in treatment.

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density. Chronic inflammation may also contribute to the risk of bone loss. There were 34,500 patients involved in the study, ranging in age from 18 to 85. For those who have eczema and have been treated with steroids, it may be wise to have a DEXA (bone) scan.

Are supplements the answer?

The thought of supplements somehow seems more appealing for some than medicine. 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.

In a meta-analysis (involving seven randomized controlled trials, the gold standard of studies), evening primrose oil was no better than placebo in treating eczema (6). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. One positive is that these supplements only had minor side effects. But don’t look to supplements for help.

Where are we on the drug front?

The FDA approved a biologic monoclonal antibody, dupilumab (7). In trials, this injectable drug showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective.

Do probiotics have a place?

When we think of probiotics, we think of taking a pill. However, there are also potentially topical probiotics with atopic dermatitis. In preliminary in-vitro (in a test tube) studies, the results look intriguing and show that topical probiotics from the human microbiome (gut) could potentially work as well as steroids (8). This may be part of the road to treatments of the future. However, this is in very early stage of development.

What about lifestyle modifications?

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 (9).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (10).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15 to 20 percent of patients who suffer some level of eczema. For example, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin had all but cleared.

I also have a personal interest in eczema. I suffered from hand eczema, where my hands would become painful and blotchy and then crack and bleed. This all stopped for me when I altered my diet many years ago.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (11). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising topical probiotics ahead and medications for the hard to treat. It might be best to avoid long-term systemic steroid use; it could not only impact the skin but also may impact the bone. Lifestyle modifications appear to be very effective, at least at the anecdotal level.

References:

(1) J Allergy Clin Immunol. 2013;132(5):1132-1138. (2) BMC Dermatol. 2013;13(14). (3) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (4) uptodate.com. (5) JAMA Dermatol. 2015;151(1):33-41. (6) Cochrane Database Syst Rev. 2013;4:CD004416. (7) Medscape.com. (8) ACAAI 2014: Abstracts P328 and P329. (9) Allergy. 2010 Jun 1;65(6):758-765. (10) J Am Acad Dermatol. 2004;50(3):391-404. (11) Contact Dermatitis 2008; 59:43-47.

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

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Studies have shown that eating less animal protein may prolong your life. Stock photo
Plant protein trumps animal protein

By David Dunaief, M.D.

Dr. David Dunaief

When asked what is more important, longevity or healthy aging (quality of life), more people choose the latter. Well, it turns out the two are not mutually exclusive.

The number of 90-year-olds is growing by leaps and bounds. According to the National Institutes of Health, those 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 these people have in common? According to one study, they tend to have fewer chronic morbidities or diseases. Thus, they tend to have a better quality of life with a greater physical func-tioning and mental acuity (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).

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

We are told time and time again to exercise. But how much do we need, and how can we get the best quality? In a 2014 study, the results showed that 5 to 10 minutes of daily running, regardless of the pace, can have a significant impact on life span by decreasing cardiovascular mortality and all-cause mortality (4).

Amazingly, even if participants ran fewer than six miles per 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. Here is the kicker: Those who ran for this very short amount of time potentially added three years to their life span. There were 55,137 participants ranging in age from 18 to 100 years old.

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).

Diet

A long-standing paradigm is that we need to eat sufficient animal protein. However, there have been cracks developing in this façade, especially as it relates to longevity. In an observational study using NHANES III data, results show that those who ate a high-protein diet (greater than 20 percent from protein) had a twofold increased risk of all-cause mortality, a four times increased risk of cancer mortality and a four times increased risk of dying from diabetes (6). This was over a considerable duration of 18 years and involved almost 7,000 participants ranging in age at the start of the study from 50 to 65.

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.

Interestingly, those who are over age 65 may benefit from more animal protein in reducing the risk of cancer. However, there was a significantly increased risk of diabetes mortality across all age groups eating a high animal protein diet. The researchers therefore concluded that lower animal protein may be wise at least during middle age.

The Adventists Health Study 2 trial reinforced this data. It looked at Seventh-day Adventists, a group that emphasizes a plant-based diet, and found that those who ate animal protein up to once a week had a significantly reduced risk of dying over the next six years compared to those who were more frequent meat eaters (7). This was an observational trial with over 73,000 participants and a median age of 57 years old.

Inflammation

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’ longevity (8). In fact, 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 takeaway from this study is that IL-6 is a relatively common biomarker for inflammation that 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, specifically running, can lead to a substantial increase in healthy life span. 

Protein from plants may trump protein from animal sources in reducing the risk of mortality from all causes, from diabetes and from heart disease. This does not necessarily mean that one needs to be a vegetarian to see the benefits. IL-6 may be a useful marker for inflammation, which could help predict healthy or unhealthy outcomes. Therefore, why not have a discussion with your doctor about testing to see if you have an elevated IL-6? 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) Cell Metab. 2014;19:407-417. (7) JAMA Intern Med. 2013;173:1230-1238. (8) CMAJ. 2013;185:E763-E770.

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

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Diet and exercise are the first line of defense for those living with diabetes. Stock photo

Taking your blood pressure medications at night has beneficial effects

By David Dunaief, M.D.

Dr. David Dunaief

Not surprisingly, soda – with 39 grams of sugar per 12-ounce can – is associated with increased risk of diabetes. However, the drink with the lowest amount of sugar is wine, red or white. Even more surprising, it may have benefits in reducing complications associated with diabetes. Wine has about 1.2 grams of sugar in 5 ounces. Per ounce, soda has the most sugar, and wine has the least.

Why is this important? The prevalence of diabetes currently sits at 9.4 percent of the U.S. population, while another 84 million have prediabetes (HbA1C of 5.7-6.4 percent) (1).

For those with diabetes, cardiovascular risk and severity may not be equal between the sexes. In two trials, women had greater risk than men. In one study, women with diabetes were hospitalized due to heart attacks at a more significant rate than men, though both had substantial increases in risk, 162 percent and 96 percent, respectively (2). This was a retrospective (backward-looking) study.

What may reduce risks of disease and/or complications? Fortunately, we are not without options. Several factors may help. These include the timing of blood pressure medications, lifestyle modifications (diet and exercise) and, yes, wine.

Diet trumps drugs for prevention

All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is not only disappointing, but it is a disservice; lifestyle changes may be more effective in preventing this disease. In a head-to-head comparison study (Diabetes Prevention Program), diet plus exercise bests metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.

There were three groups in the study: those receiving a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; those taking metformin, 875 mg twice a day; and a placebo group. Diet and exercise reduced the risk of diabetes by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. While these are impressive results that speak to the use of lifestyle modification and to metformin, this is not the optimal diabetes diet.

Is wine really beneficial?

Alcohol in general has mixed results. Wine is no exception. However, the CASCADE trial, a randomized controlled trial, considered the gold standard of studies, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (4).

Patients were randomized into three groups, each receiving a drink with dinner nightly; one group received 5 ounces of red wine, another 5 ounces of white wine, and the control group drank 5 ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed on how to follow a Mediterranean-type diet.

Does this mean diabetes patients should start drinking wine? Not necessarily, because this is a small, though well-designed, study. Wine does have calories, and these were also well-controlled type 2 diabetes patients who generally were nondrinkers.

Drugs (not diabetes drugs) show good results

Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (5). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.

It seems that controlling sleep-time blood pressure is more predictive of risk for diabetes than morning or 48-hour ambulatory blood pressure monitoring. This study had a long duration of almost six years with about 2,000 participants.

The blood pressure medications used in the trial were ACE inhibitors, angiotensin receptor blockers and beta blockers. The first two medications have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, the drugs that blocked RAAS in the kidneys had the most powerful effect on preventing diabetes. 

Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes. Interestingly, the RAAS blocking drugs are the same drugs that protect kidney function when patients have diabetes.

We need to reverse the trend toward higher diabetes prevalence. Diet and exercise are the first line for prevention. Even a nonideal diet, in comparison to medication, had better results, though medication such as metformin could be used in high-risk patients that were having trouble following the diet. A modest amount of wine, especially red, may have effects that reduce cardiovascular risk. Blood pressure medications taken at night, especially those that block RAAS in the kidneys, may help significantly to prevent diabetes.

References:

(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Ann Intern Med. 2015;163(8):569-579. (5) Diabetologia. Online Sept. 23, 2015.

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 or consult your personal physician.

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Stock photo
Reducing oxidative stress may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

Heart attacks and heart disease get a lot of attention, but chronic heart failure is often overlooked by the press. The reason may be that heart failure is not acute like a heart attack.

To clarify by using an analogy, a heart attack is like a tidal wave whereas heart failure is like a tsunami. You don’t know it’s coming until it may be too late. Heart failure is an insidious (slowly developing) disease and thus may take years before it becomes symptomatic. It also increases the risk of heart attack and death.

There are about 5.7 million Americans with heart failure, and experts project that will increase to 8 million by 2030 (1). Not surprisingly, incidence of heart failure increases with age (2).

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands and may decompensate. It is a complicated topic, for there are two types — systolic heart failure and diastolic heart failure. 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.

We have more evidence-based medicine, or medical research, on systolic heart failure. Fortunately, both types can be diagnosed with the help of an echocardiogram, an ultrasound of the heart. The signs and symptoms may be similar, as well, and include shortness of breath on exertion or when lying down, edema or swelling, reduced exercise tolerance, weakness and fatigue. The risk factors for heart failure include diabetes, coronary artery disease, high blood pressure, obesity, smoking, heart attacks and valvular disease.

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, iron and the supplement CoQ10 impact heart failure.

Effect of diet

If we look beyond the usual risk factors mentioned above, oxidative stress may play an important role as a contributor to HF. Oxidative stress is thought to potentially result in damage to the inner lining of the blood vessels, or endothelium, oxidation of cholesterol molecules and a decrease in nitric oxide, which helps vasodilate blood vessels.

In a population-based, prospective (forward-looking) study, called the Swedish Mammography Cohort, results show that a diet rich in antioxidants reduces the risk of developing HF (3). 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.

This nutrient-dense approach to diet increased oxygen radical absorption capacity. Oxygen radicals have been implicated in cellular damage and DNA damage, potentially as a result of increasing chronic inflammation. 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, since it is an observational study, 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.

CoQ10 supplementation

Coenzyme Q10 is a substance produced by the body that helps the mitochondria (the powerhouse of the cell) produce energy. It is thought of as an antioxidant. 

Results of the Q-SYMBIO study, a randomized controlled trial, showed an almost 50 percent reduction in the risk of all-cause mortality and 50 percent fewer cardiac events with CoQ10 supplementation (4). This one randomized controlled trial followed 420 patients for two years who had severe heart failure. This involved using 100 mg of CoQ10 three times a day compared to placebo.

The lead author goes as far as to suggest that CoQ10 should be part of the paradigm of treatment. This the first new “drug” in over a decade to show survival benefits in heart failure. Thus, if you have heart failure, you may want to discuss CoQ10 with your doctor.

Iron deficiency

Anemia and iron deficiency are not synonymous, since iron deficiency can occur without anemia. A recent 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 (5).

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. Thus, it behooves us to 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, for these are correctable. 

I am not typically a supplement advocate; however, based on the latest results, CoQ10 seems like a compelling therapy to reduce risk of further complications and potentially death. Consult with your doctor before taking CoQ10 or any other supplements, especially if you have heart failure.

References:

(1) Card Fail Rev. 2017 Apr; 3(1):7–11. (2) J Am Coll Cardiol. 2003;41(2):21. (3) Am J Med. 2013 Jun:126(6):494-500. (4) JACC Heart Fail. 2014 Dec;2(6):641-649. (5) Am Heart J. 2013;165(4):575-582.

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 or consult your personal physician.     

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Smoking and salt consumption add to the risk of GERD. Stock photo
Simple lifestyle changes are among the most effective treatments

By David Dunaief, M.D.

Dr. David Dunaief

It seems like everyone is diagnosed with gastroesophageal reflux disease (GERD). I exaggerate, of course, but the pharmaceutical companies do an excellent job of making it appear that way with advertising. Wherever you look there is an advertisement for the treatment of heartburn or indigestion, both of which are related to reflux disease.

GERD, also known as reflux, affects as much as 40 percent of the U.S. population (1). Reflux disease typically results in symptoms of heartburn and regurgitation brought on by stomach contents going backward up the esophagus. For some reason, the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Of course, a portion of reflux is physiologic (normal functioning), especially after a meal (2).

GERD risk factors are diverse. They range from lifestyle — obesity, smoking cigarettes and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Diet issues include triggers like spicy foods, peppermint, fried foods and chocolate.

Smoking and salt’s role

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Medications

The most common and effective medications for the treatment of 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. Here, I will focus on PPIs, for which more than 113 million prescriptions are written every year in the U.S. (6).

PPIs include Nexium (esomeprazole), Prilosec (omeprazole), Protonix (pantoprazole) and Prevacid (lansoprazole). They have demonstrated efficacy for short-term use in the treatment of Helicobacter pylori-induced (bacteria overgrowth in the gut) peptic ulcers, GERD symptoms and complication prevention and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

However, they are often used long-term as maintenance therapy for GERD. PPIs used to be considered to have mild side effects. Unfortunately, evidence is showing that this may not be true. 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, not 10 years. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use are increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Bacterial infection

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

B12 deficiencies

Suppressing hydrochloric acid produced in the stomach may result in malabsorption issues if turned off for long periods of time. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. B12 was not absorbed properly from food, but the PPIs did not affect B12 levels from supplementation (9). Therefore, if you are taking a PPI chronically, it is worth getting your B12 and methylmalonic acid (a metabolite of B12) levels checked and discussing possible supplementation with your physician if you have a deficiency.

Lifestyle modifications

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 (10). In the same study already mentioned with smoking and salt, fiber and exercise both had the opposite effect, reducing the risk of GERD (5). This was a prospective (forward-looking) trial. The 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 (11).

Obesity

In one study, obesity exacerbated GERD. What was interesting about the study is that researchers used manometry, which measures pressure, to show that obesity increases the pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index. This is yet another reason to lose weight.

Eating prior to bed — myth?       

Though it may be simple, it is one of the most powerful modifications we can make to avoid GERD. A study that 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 prior to bedtime. Of note, this is 10 times the increased risk of the smoking effect (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.”

Although there are a number of ways to treat GERD, the most comprehensive have to do with modifiable risk factors. Drugs have their place in the arsenal of choices, but lifestyle changes are the first — and most effective — approach in many instances. Consult your physician before stopping PPIs since there may be rebound hyperacidity (high acid produced) if they are stopped abruptly.

References:

(1) Gut 2005;54(5):710. (2) Gastroenterol Clin North Am. 1996;25(1):75. (3) emedicinehealth.com. (4) Gut 2004 Dec.; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) JW Gen Med. Jun. 8, 2011. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov/safety/medwatch/safetyinformation. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar.; 130:639-649. (13) Am J Gastroenterol. 2005 Dec.;100(12):2633-2636.

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 or consult your personal physician.

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Follow a nutrient-dense, plant-rich diet for best results. kale/Stock photo
Diet changes and exercise can reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

When we think of the most prevalent chronic diseases, heart disease, stroke, cancer, diabetes and others come to mind. However, there is also a chronic liver disease — nonalcoholic fatty liver disease — a conglomeration of fats, including triglycerides.

The problem with this disease is that it could lead to nonalcoholic steatohepatitis (fatty liver hepatitis), fibrosis (too much connective tissue, due to repair) and eventually cirrhosis, which might ultimately result in cancer (hepatocellular carcinoma).

Fortunately, the risk of going down this dangerous path is relatively small. Most of the time, it remains a mild fatty liver disease.

Although it is rare, a study presentation in 2012 at the American Association for the Study of Liver Diseases suggested that NAFLD was the third most common risk for hepatocellular carcinoma behind infection and alcohol abuse (1). 

Some study patients with hepatocellular carcinoma progressed to this level without first having cirrhosis. Those patients who developed liver cancer but did not have cirrhosis were more likely to have diabetes, obesity, high blood pressure and/or a high cholesterol profile. NAFLD occurs more frequently in males than females, and it needs to be taken very seriously.

The prevalence of NAFLD, which is benign in most cases, is relatively high, with incidences rising in the U.S. from 15 to 25 percent in the five-year period between 2005 and 2010 (2). In fact, a study shows that adolescents between the ages of 12 and 18 have seen a threefold increase in NAFLD, from 3.3 percent to almost 10 percent, in the last 20 years, according to data from the National Health and Nutrition Examination Survey (3). This correlated primarily with obesity, but the rise outstrips the rate of increase in obesity in this adolescent population.

How is it diagnosed?

When liver enzymes are elevated, usually two to five times normal, then it tends to be more commonly diagnosed (4). These liver enzymes include aspartate aminotransferase and alanine aminotransferase. What makes this disease diagnosis more difficult is that patients without elevated liver enzymes may have the disease and, in most cases, they have no symptoms.

The gold standard of diagnosis is through a liver biopsy, though this is invasive and thus has its dangers. Another method is through ultrasound, a first-line diagnosis method. Ultrasound is 60 to 94 percent sensitive and 66 to 95 percent specific (5). Though it is not the most accurate, it has the fewest side effects. Ultrasound is also technician dependent in terms of grading the amount of fatty infiltrates in the liver — mild, moderate and severe. Unfortunately, the milder the amount of fatty infiltrates, the less accurate the reading. Other methods for diagnosis include transient elastography, computed tomography and magnetic resonance.

 What might be the cause?

Follow a nutrient-dense, plant-rich diet for best results.

One theory is that intraperitoneal fat (visceral fat or central obesity) infiltrates the liver through the portal vein, resulting in insulin resistance and fatty liver (6). Therefore, it is not surprising that, along with insulin resistance, there is glucose intolerance. High triglycerides and low HDL (“good”) cholesterol are also commonly associated with the disease (7).

How can we alter this disease?

The good news is that NAFLD is potentially reversible through lifestyle modifications, including changes in diet and an increase in exercise. With exercise, the premise is that the more activity a patient gets, the higher the probability of metabolizing the liver fat.

In an epidemiologic study of over 3,000 patients using data from NHANES, results showed that those with NAFLD are significantly less active than those without the disease. It did not matter the type of activity; NAFLD patients did less of it. In fact, patients who had both diabetes and NAFLD were found to do the least amount of physical activity (8). The scary aspect is that patients with NAFLD have a significant eight times increased risk of cardiovascular death between the ages of 45 and 54 (9). And we know activity improves cardiovascular results.

In a meta-analysis (a group of 23 studies ranging from one to six months in duration) that used the Cochrane database, the results showed a significant reduction in fat content in the liver and a decrease in liver enzymes when lifestyle modifications were employed (10). Reduction in weight had the most substantial correlation with the results. Of the 23 studies, five that looked at liver cells on a microscopic level showed a reduction in inflammation that occurred with lifestyle changes. In addition, there were also improved glucose levels and sensitivity to insulin after the modifications.

In my practice, I have seen several patients with liver enzymes elevated to at least twice normal levels. After following a nutrient-dense, plant-rich diet, they saw their liver enzymes significantly reduced or returned to normal levels within a few months. One patient’s liver enzymes had been raised for 20 years without a known cause, and a first-line relative had recently been diagnosed with liver cancer.

If you have risk factors for nonalcoholic fatty liver disease, such as obesity, diabetes, high blood pressure and high cholesterol, I recommend having your liver enzymes checked on a regular basis. Those with family histories of elevated liver enzymes and hepatocellular carcinoma (liver cancer) may also want to get a scan, at least with ultrasound.

The best way to treat NAFLD is with lifestyle modifications, and while it is never too late to treat NAFLD, it is better to discover the disease earlier to reduce your risk of complications. If you are obese, NAFLD is one more important reason to transform your body composition by reducing fat mass.

References:

(1) AASLD. 2012 Nov. 11; Abstract 97. (2) World J Gastroenterol. 2017 Dec 21; 23(47): 8263–8276. (3) DDW. 2012 May 18; Abstract 705. (4) Hepatology. 2003; 37:1286-1292. (5) J Hepatol. 2009; 51:433–445. (6) Arterioscler Thromb Vasc Biol. 1990; 10:493-496. (7) Gastroenterology. 1999; 116:1413–1419. (8) Aliment Pharmacol Ther. 2012; 36:772-781. (9) Am J Gastroenterol. 2008; 103:2263–2271. (10) J Hepatol. 2012 Jan.; 56:255-266.

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 or consult your personal physician. 

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Stock photo
Diabetic retinopathy can lead to blurred vision and blindness

By David Dunaief, M.D.

Dr. David Dunaief

With diabetes, we tend to concentrate on stabilization of the disease as a whole. This is a good thing. However, there is not enough attention spent on microvascular (small vessel disease) complications of diabetes, specifically diabetic retinopathy, which is an umbrella term.

This disease, a complication of diabetes that is related to sugar control, can lead to blurred vision and blindness. There are at least three different disorders that make up diabetic retinopathy. These are dot and blot hemorrhages, proliferative diabetic retinopathy and diabetic macular edema. The latter two are the most likely disorders to cause vision loss. Our focus for this article will be on diabetic retinopathy as a whole and on diabetic macular edema, more specifically.

Diabetic retinopathy is the number one cause of vision loss in those who are 25 to 74 years old (1). Risk factors include duration of diabetes, glucose (sugar) that is not well controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2).

What is diabetic macula edema, also referred to as DME? This disorder is swelling, due to extracellular fluid accumulating in the macula (3). The macula is a yellowish oval spot in the central portion of the retina — in the inner segment of the back of the eye — and it is sensitive to light. The macula is the region with greatest visual acuity. When fluid builds up from blood vessels leaking, there is potential loss of vision.

The highest risk factor for DME is for those with the longest duration of diabetes (4). DME is traditionally treated with lasers. But intravitreal (intraocular — within the eye) injections of a medication known as ranibizumab (Lucentis) may be as effective as laser. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated after having DME for a year or more, patients can experience permanent loss of vision (5).

In a cross-sectional study (a type of observational study) using NHANES data from 2005-2008, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (6). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietitian in more than a year — or never.

The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes. Many patients are unaware of the association between vision loss and diabetes.

Treatment options: lasers and injections

There seems to be a potential paradigm shift in DME treatment. Traditionally, patients had been treated with lasers. The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab, whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7).

Increased risk with diabetes drugs

Diabetic retinopathy is the number one cause of vision loss in ages 25 to 74. Stock photo

You would think that drugs to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective (backward-looking) 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 (8). 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.

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 is in contrast to a previous ACCORD eye substudy, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). 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 of these studies were not without 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 (10). Thus, there needs to be a prospective (forward-looking) trial done to sort out these results.

Diet

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 (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But 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 complications (12, 13).

The best way to avoid diabetic retinopathy is obviously to prevent diabetes. Barring that, it’s to have sugars well controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones, which include rosiglitazone (Avandia) and pioglitazone (Actos).

References:

(1) Diabetes Care. 2014;37 (Supplement 1):S14-S80. (2) JAMA. 2010;304:649-656. (3) www.uptodate.com. (4) JAMA Ophthalmol online. 2014 Aug. 14. (5) www.aao.org/ppp. (6) JAMA Ophthalmol. 2014;132:168-173. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.

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 or consult your personal physician. 

٭We invite you to check out our weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

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Exercising 30 minutes four to five times a week is best. Stock photo
It is possible to overdo exercise for weight loss purposes

By David Dunaief, M.D.

Dr. David Dunaief

When we make a New Year’s resolution to exercise regularly, the goal is often either to change body composition, to lose weight, or at least to maintain weight. How much exercise is best for these purposes? It is a hotly debated topic. You would think the answer would be straightforward, since exercise helps us prevent and resolve a great many diseases.

At the same time, we hope exercise impacts our weight. Does it? It is important to manage our expectations, before we start exercising. There are some intriguing studies that address whether exercise has an impact on weight management. The short answer is yes; however, not always in ways we might expect.

Then the questions become: What type of exercise should we be doing? How frequently and for how long? Let’s look at the evidence.

Duration

It makes sense that the more we exercise to lose weight, the better, or at least that is what we thought. In a small randomized controlled trial (RCT), the gold standard of studies, results showed that the moderate group in terms of duration saw the most benefit for weight loss (1). 

There were three groups in the study — a sedentary group (low), a group that did 30 minutes per day of aerobic exercise (moderate) and a group that did 60 minutes per day of aerobic exercise (high).

Perhaps obviously, the sedentary group did not see a change in weight. Surprisingly, though, the group that did 30 minutes of exercise per day experienced not only significantly more weight loss than the sedentary group, but also more than the 60-minute exercise group. The aerobic exercises involved biking, jogging or other perspiring activities. These were healthy young men that were overweight, but not obese, and the study duration was three months.

The authors surmise that the reason for these results is that the moderate group may have garnered more energy and moved around more during the remainder of the day, as sensors showed. The highest exercise group was sedentary through most of the rest of day, probably due to fatigue. Also, it seemed that the highest exercise group ate more than the moderate group, though the difference was not statistically significant. While this study is of impressive quality, it is small and of short duration. Nonetheless, its results are encouraging.

Postmenopausal women

As a group, postmenopausal women have considerable difficulty losing weight and maintaining weight loss. In a secondary analysis of a randomized controlled trial, there were three aerobic exercise groups differentiated by the number of kcal/kg per week they burned: 4, 8 and 12 (2). All of the groups saw significant reductions in waist circumference. Interestingly, however, a greater number of steps per day outside of the training, measured by pedometer, were primarily responsible for improved waistline circumference, regardless of the intensity of the workouts.

But it gets more intriguing, because the group that exercised with the lowest intensity was the only one to see significant weight loss. More is not always better, and in the case of exercise for weight loss, less may be more. This study reinforces the suppositions made by the authors of the previous men’s study: We should exercise to a point where it is energy inducing and not beyond.

Premenopausal women

Not to ignore younger women, those who were premenopausal also saw a significant benefit with weight maintenance and exercise after having intentionally lost weight.

In a prospective (forward-looking) study, young women who did at least 30 minutes of exercise four to five days per week were significantly less likely to regain weight that they had lost, compared to those who were sedentary after losing weight (3).

Some of the strengths of this study were its substantially long six-year follow-up period and its large size, involving over 4,000 women between the ages of 26 and 45. Running and jogging were more impactful in preventing weight gain than walking with alacrity. However, all forms of exercise were superior to the sedentary group.

Aerobic exercise and resistance training

In another RCT with 119 overweight or obese adults, aerobic exercise four to five times a week for about 30 minutes each was most effective for weight loss and fat reduction, while resistance training added lean body mass. Lean body mass is very important. It does not cause weight reduction, but rather increased fitness (4).

With weight loss, it’s important to delineate between thin and fit. Fitness includes a body composition of decreased body fat and increased lean muscle mass. To help achieve fit level, it’s probably best to have a combination of aerobic and anaerobic exercise (resistance training). Both contribute to achieving this goal.

In conclusion, exercise can play a significant role in weight, whether with weight reduction, weight maintenance or increasing lean body mass. It appears that 30 minutes of exercise four to five times a week is best. Longer is not necessarily better.

What is most important, however, is to exercise to the point where it energizes you, but doesn’t cause fatigue. This is because it is important not to be sedentary the rest of the day, but to remain active. We should also include a complete package of lifestyle modifications in general — diet, exercise and stress reduction — to get the most compelling results.

References:

(1) Am J Physiol Regul Integr Comp Physiol. 2012 Sep 15;303(6):R571-R579. (2) Am J Prev Med. 2012;43(6):629-635. (3) Obesity 2010;18(1):167-174. (4) J Appl Physiol. 2012 Dec;113(12):1831-1837.

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 or consult your personal physician. 

٭We invite you to check out our weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

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By David Dunaief, M.D.

Dear Santa,

Dr. David Dunaief

This time of year, people around the world are no doubt sending you lists of things they want through emails, blogs, tweets and old-fashioned letters. In the spirit of giving, I’d like to offer you some advice.

Let’s face it: You aren’t exactly the model of good health. Think about the example you’re setting for all those people whose faces light up when they imagine you shimmying down their chimneys. You have what I’d describe as an abnormally high BMI (body mass index). Since you are a role model to millions, this sends the wrong message.

We already have an epidemic of overweight kids, leading to an ever increasing number of type 2 diabetics at younger and younger ages. According to the Centers for Disease Control and Prevention, as of 2015, more than 100 million U.S. adults are living with diabetes or prediabetes. It complicates the issue that approximately two-thirds of the U.S. population is overweight and/or obese. This is just one of many reasons we need you as a shining beacon of health.

Obesity has a much higher risk of shortening a person’s life span, not to mention quality of life and self-image. The most dangerous type of obesity is an increase in visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if a waistline, measured from the navel, is greater than or equal to 40 inches for a man, and is greater than or equal to 35 inches for a woman. The chances of diseases such as pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is a chance for you to lead by example (and, maybe by summer, to fit into those skinny jeans you hide in the back of your closet). Think of the advantages to you of being slimmer and trimmer. Your joints wouldn’t ache with the winter cold, and you would have more energy. Plus, studies show that with a plant-based diet, focusing on fruits and vegetables, you can reverse atherosclerosis, clogging of the arteries.

The importance of a good diet not only helps you lose weight, but avoid strokes, heart attacks and peripheral vascular diseases, among other ailments. But you don’t have to be vegetarian; you just have to increase your fruits, vegetables and whole-grain foods significantly. With a simple change, like eating a handful of raw nuts a day, you can reduce your risk of heart disease by half. Santa, future generations need you. Losing weight will also change your center of gravity, so your belly doesn’t pull you forward. This will make it easier for you to keep your balance on those steep, icy rooftops.

Exercise will help, as well. Maybe for the first continent or so, you might want to consider walking or jogging alongside the sleigh. As you exercise, you’ll start to tighten your abs and slowly see fat disappear from your midsection. Your fans everywhere leave you cookies and milk when you deliver presents. It’s a tough cycle to break, but break it you must. You — and your fans — need to see a healthier Santa. 

You might let slip that the modern Santa enjoys fruits, especially berries, and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in humus, which have substantial antioxidant qualities and can help reverse disease. And, of course, skip putting candy in the stockings. No one needs more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a piece, yourself.

As for your loyal fans, you could place fitness videos under the tree. In fact, you and your elves could make workout videos for those of us who need them, and we could follow along as you showed us “12 Days of Workouts with Santa and Friends.” Who knows, you might become a modern version of Jane Fonda or Richard Simmons or even the next Shaun T!

How about giving athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games? You could even give wearable devices that track step counts and bike routes or stuff gift certificates for dance lessons into people’s stockings. These might influence the recipients to be more active.

By doing all this, you might also have the kind of energy that will make it easier for you to steal a base or two in this season’s North Pole Athletic League’s Softball Team. The elves don’t even bother holding you on base anymore, do they?

As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll find yourself parking the sleigh farther away and skipping from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Think about something much closer to home, even your reindeer won’t have to work so hard. You might also fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!

Wishing you good health in the new year,

David

P.S. I could really use some new baseballs, if you have a little extra room in your sleigh.

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 or consult your personal physician. 

٭We invite you to check out our new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.٭

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Studies show that walking a modest distance can reduce triglyceride levels. Stock photo
Reducing carbohydrates may be more important than restricting calories

By David Dunaief, M.D.

Dr. David Dunaief

Triglycerides are part of the lipid, or cholesterol, profile. They get less attention than the other substances, HDL (“good”) and LDL (“bad”) cholesterol, but they’re no less significant. 

For 30 years, we have debated whether a high triglyceride level is a biomarker for cardiovascular disease — heart disease and stroke — or an independent risk in its own right (1, 2). Either way, triglycerides are important.

What are they? The most rudimentary explanation is that they are a kind of fat in the blood. They are composed of sugar alcohol and three fatty acids. Thus, it’s no surprise that alcohol, sugars and excess calorie consumption may be converted into triglycerides.

Risk factors for high triglycerides include obesity, smoking, a high carbohydrate diet, uncontrolled diabetes, hypothyroidism (underactive thyroid), cirrhosis (liver disease), excessive alcohol consumption and some medications (3).

What levels are normal? Optimal levels are <100 mg/dL; however, less than 150 mg/dL is considered within normal range. Borderline triglycerides are 150–199 mg/dL, high levels are 200–499 mg/dL, and very high are >500 mg/dL (3).

While medicines that focus on triglycerides, fibrates and niacin can lower them significantly, this reduction may not result in clinical benefits, such as reducing the risk of cardiovascular events. The ACCORD Study, a randomized controlled trial, questioned the effectiveness of medication; when these therapies were added to statins in type 2 diabetes patients, they did not further reduce the risk of cardiovascular disease and events (4). Instead, it seems that lifestyle modifications may be the best way to control triglyceride levels. Let’s look at the evidence.

Exercise — timing and intensity

If you need a reason to exercise, here is a really good one. Study results showed that walking a modest distance with alacrity and light weight training approximately an hour after eating (postprandial) reduced triglyceride levels by 72 percent (5). However, if patients did the same workout prior to eating, postprandial triglycerides were reduced by 25 percent. This is still good, but not as impressive. 

Participants walked a modest distance of just over 1 mile (2 kilometers). This was a small pilot study of 10 young healthy adults for a very short duration. The results are intriguing, nonetheless, since there are few data that give specifics on the optimal amount and timing of exercise.

Exercise trumps calorie restriction

There is good news for those who want to lower triglycerides: Calorie restriction may not be the best answer. Instead, we probably should be looking at exercise and carbohydrate intake.

In a well-controlled trial, results showed that those who walked and maintained 60 percent of their maximum heart rate, which is a modest level, showed an almost one-third reduction in triglycerides compared to the control group (maintain caloric intake and no exercise expenditure) (6). Those who restricted their calorie intake saw no difference compared to the control. This was a small study of 11 young adult women. Thus, calorie restriction was trumped by exercise.

Carbohydrate reduction, not calorie restriction

In addition, when calorie restriction was compared to carbohydrate reduction, results showed that carbohydrate reduction was more effective at lowering triglycerides (7). In this small, but well-designed study, patients with nonalcoholic fatty liver disease were randomized to one of two diets, lower calorie (1200–1500 kcal/day) or lower carbohydrate (20 g/day). Both groups lost similar amounts of weight and significantly reduced triglycerides, but the lower carbohydrate group reduced triglycerides by 55 percent versus 28 percent for the lower calorie group. The reason for this difference may have to do with oxidation in the liver and the body as a whole. However, the weakness of this study was its duration of only two weeks.

Fasting versus nonfasting blood tests

The paradigm has been that, when cholesterol levels are drawn, fasting levels provide a more accurate reading. Except this may not be true.

NHANES III data suggest that nonfasting and fasting levels yield similar results related to all-cause mortality and cardiovascular mortality risk. LDL levels were similarly predictive, regardless of whether a patient had fasted or not. The researchers used 4,299 pairs of fasting and nonfasting cholesterol levels. The duration of follow-up was strong, with a mean of 14 years (8).

With regards to stroke risk assessment, nonfasting triglycerides may be more valuable than fasting. In a study involving 13,596 participants, results showed that as nonfasting triglycerides rose, the risk of stroke also rose significantly (9). Compared to those who had levels below 89 mg/dL (the control), those with 89–176 mg/dL had a 1.3-fold increased risk of cardiovascular events, whereas those within the range of 177–265 mg/dL had a twofold increase, and women in the highest group (>443 mg/dL) had an almost fourfold increase. The results were similar for men, with a threefold increase.

The benefit of nonfasting is that it is more realistic and, according to the authors, also involves remnants of VLDL and chylomicrons, other components of the cholesterol profile that interact with triglycerides and may affect the inner part (endothelium) of the arteries.

What have we learned? Triglycerides need to be discussed. Elevated triglycerides may result in heart disease or stroke. The higher the levels, the more likely there will be increased risk of mortality — both all-cause and cardiovascular. Therefore, we ideally should reduce levels to less than 100 mg/dL.

Lifestyle modifications using carbohydrate restriction and modest levels of exercise after a meal may achieve the best results, though the studies are small and need more research. Nonfasting levels may be as important as fasting levels when it comes to triglycerides and the cholesterol profile as a whole; they potentially give a more realistic view of cardiovascular risk, since we don’t live in a vacuum and fast all day.

References:

(1) Circulation. 2011;123:2292-2333. (2) N Engl J Med. 1980;302:1383–1389. (3) nlm.nih.gov. (4) N Engl J Med. 2010;362:1563-1574. (5) Med Sci Sports Exerc. 2013;45(2):245-252. (6) Med Sci Sports Exerc. 2013;45(3):455-461. (7) Am J Clin Nutr. 2011;93(5):1048-1052. (8) Circulation Online. 2014 July 11. (9) JAMA 2008;300:2142-2152.

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

٭We invite you to check out our new weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com

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