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Medical Compass

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A nutrient-dense, plant-based diet appears to prevent and help manage diseases that can affect vision including cataracts. Stock photo
Diet can have a significant impact on cataract risk

By David Dunaief, M.D.

Dr. David Dunaief

Cataracts affect a substantial portion of the U.S. population. In fact, 24.4 million people in the U.S. over the age of 40 are currently afflicted, and this number is expected to increase approximately 58 percent by the year 2030 — only 12 years from now — according to estimates by the National Eye Institute (1).

Cataracts are defined as an opacity or cloudiness of the lens in the eye, which decreases vision over time, as it progresses. It’s very common for both eyes to be affected. We often think of cataracts as a symptom of age, but we can take an active role in preventing them.

There are enumerable modifiable risk factors including diet; smoking; sunlight exposure; chronic diseases, such as diabetes and metabolic syndrome; steroid use; and physical inactivity. I am going to discuss the dietary factor.

Prevention

In a prospective (forward-looking) study, diet was shown to have substantial effect on the risk reduction for cataracts (2). This study was the United Kingdom group, with 27,670 participants, of the European Prospective Investigation into Cancer and Nutrition (EPIC) trial. Participants completed food frequency questionnaires between 1993 and 1999. Then, they were checked for cataracts between 2008 and 2009.

There was an inverse relationship between the amount of meat consumed and cataract risk. In other words, those who ate a great amount of meat were at higher risk of cataracts. “Meat” included red meat, fowl and pork. These results followed what is termed a dose-response curve. 

Compared to high meat eaters, every other group demonstrated a significant risk reduction as you progressed along a spectrum that included low meat eaters (15 percent reduction), fish eaters (21 percent reduction), vegetarians (30 percent reduction) and finally vegans (40 percent reduction). 

There really was not that much difference between high meat eaters, those having at least 3.5 ounces, and low meat eaters, those having less than 1.7 ounces a day, yet there was a substantial decline in cataracts. Thus, you don’t have to become a vegan to see an effect.

In my clinical experience, I’ve also had several patients experience reversal of their cataracts after they transitioned to a nutrient-dense, plant-based diet. I didn’t think this was possible, but anecdotally, this is a very positive outcome and was confirmed by their ophthalmologists (eye doctors).

Mechanism of action

Oxidative stress is one of the major contributors to the development of cataracts. In a review article that looked at 70 different trials for the development of cataract and /or maculopathies, such as age-related macular degeneration, the authors concluded antioxidants, which are micronutrients found in foods, play an integral part in prevention (3). 

The authors go on to say that a diet rich in fruits and vegetables, as well as lifestyle modification with cessation of smoking and treatment of obesity at an early age, help to reduce the risk of cataracts. Thus, you are never too young or too old to take steps to prevent cataracts.

How do you treat cataracts?

The only effective way to treat cataracts is with surgery; the most typical type is phacoemulsification. Ophthalmologists remove the opaque lens and replace it with a synthetic intraocular lens. This is done as an outpatient procedure and usually takes approximately 30 minutes. Fortunately, there is a very high success rate for this surgery. So why is it important to avoid cataracts if surgery is able to remedy the situation?

Potential consequences of surgery

There are always potential risks with invasive procedures, such as infection, even though the chances of complications are low. However, more importantly, there is a greater than fivefold risk of developing late-stage age-related macular degeneration (AMD) after cataract surgery (4). This is wet AMD, which can cause significant vision loss. These results come from a meta-analysis (group of studies) looking at more than 6,000 patients. 

It has been hypothesized that the surgery may induce inflammatory changes and the development of leaky blood vessels in the retina of the eye. However, because this meta-analysis was based on observational studies, it is not clear whether undiagnosed AMD may have existed prior to the cataract surgery, since they have similar underlying causes related to oxida tive stress.

Therefore, if you can reduce the risk of cataracts through diet and other lifestyle modifications, plus avoid the potential consequences of cataract surgery, all while reducing the risk of chronic diseases, why not choose the win-win scenario?

References:

1. nei.nih.gov. 2. Am J Clin Nutr. 2011 May; 93(5): 1128-1135. 3. Exp Eye Res. 2007; 84: 229-245. 4. Ophthalmology. 2003; 110(10): 1960. 

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

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The effects of high sodium are insidious

By David Dunaief, M.D.

Dr. David Dunaief

By now, most of us have been hit over the head with the fact that too much salt in our diets is unhealthy. Still, we respond with “I don’t use salt,” “I use very little,” or “I don’t have high blood pressure, so I don’t have to worry.” Unfortunately, these are myths. All of us should be concerned about salt or, more specifically, our sodium intake.

Excessive sodium in the diet does increase the risk of high blood pressure (hypertension); the consequences are stroke or heart disease. Approximately 90 percent of Americans consume too much sodium (1).

Now comes the interesting part. Sodium has a nefarious effect on the kidneys. In the Nurses Health Study, approximately 3,200 women were evaluated in terms of kidney function, looking at the estimated glomerular filtration rate (GFR) as related to sodium intake (2). Over 14 years, those with a sodium intake of 2,300 mg had a much greater chance of an at least 30 percent reduction in kidney function, compared to those who consumed 1,700 mg per day.

Why is this study important? Kidneys are one of our main systems for removing toxins and waste. The kidneys are where many initial high blood pressure medications work, including ACE inhibitors, such as lisinopril; ARBs, such as Diovan or Cozaar; and diuretics (water pills). If the kidney loses function, it may be harder to treat high blood pressure. Worse, it could lead to chronic kidney disease and dialysis. Once someone has reached dialysis, most blood pressure medications are not very effective.

Ironically, the current recommended maximum sodium intake is 2,300 mg per day, or one teaspoon, the same level that led to negative effects in the study. However, Americans’ mean intake is twice that level.

Excessive sodium in one’s diet can increase the risk of high blood pressure, which can lead to a stroke or heart disease. Stock photo

If we reduced our consumption by even a modest 20 percent, we could reduce the incidence of heart disease dramatically. Current recommendations from the American Heart Association indicate an upper limit of 2,300 mg per day, with an “ideal” limit of no more than 1,500 mg per day (3).

If the salt shaker is not the problem, what is? Most of our sodium comes from processed foods, packaged foods and restaurants. There is nothing wrong with eating out on occasion, but you can’t control how much salt goes into your food. My wife is a great barometer of restaurant salt use. If food from the night before was salty, she complains of not being able to get her rings off.

Do you want to lose 5 to 10 pounds quickly? Decreasing your salt intake will allow you to achieve this goal. Excess sodium causes the body to retain fluids. 

One approach is to choose products that have 200 mg or fewer per serving indicated on the label. Foods labeled “low sodium” have fewer than 140 mg of sodium, but foods labeled “reduced sodium” have 25 percent less than the full-sodium version, which doesn’t necessarily mean much. Soy sauce has 1,000 mg of sodium per tablespoon, but low-sodium soy sauce still has about 600 mg per tablespoon. Salad dressings and other condiments, where serving sizes are small, add up very quickly. Mustard has 120 mg per teaspoon. Most of us use far more than one teaspoon of mustard. Caveat emptor: Make sure to read labels on all packaged foods very carefully.

Is sea salt better than table salt? High amounts of salt are harmful, and the type is not as important. The only difference between them is slight taste and texture variation. I recommend not buying either. In addition to the health issues, salt tends to dampen your taste buds, masking the flavors of food.

If you are working to decrease your sodium intake, become an avid label reader. Sodium hides in all kinds of foods that don’t necessarily taste salty, such as breads, soups, cheeses and salad dressings. I also recommend getting all sauces on the side, so you can control how much — if any — you choose to use.

As you reduce your sodium intake, you might be surprised at how quickly your taste buds adjust. In just a few weeks, foods you previously thought didn’t taste salty will seem overwhelmingly salty, and you will notice new flavors in unsalted foods.

If you have a salt shaker and don’t know what to do with all the excess salt, don’t despair. There are several uses for salt that are actually beneficial. According to the Mayo Clinic, gargling with ¼ to ½ teaspoon of salt in eight ounces of warm water significantly reduces symptoms of a sore throat from infectious disease, such as mononucleosis, strep throat and the common cold. Having had mono, I can attest that this works.

Remember, if you want to season your food at a meal, you are much better off asking for the pepper than the salt.

References:

(1) cdc.gov. (2) Clin J Am Soc Nephrol. 2010;5:836-843. (3) heart.org.

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

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A diet high in fiber may help decrease the risk of heart disease, obesity and diabetes and has been linked to a lower incidence of some types of cancer. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Many people worry about getting enough protein, when they really should be concerned about getting enough fiber. Most of us — except perhaps professional athletes or long-distance runners — get enough protein in our diets. Protein has not prevented or helped treat diseases in the way that studies illustrate with fiber. 

As I mentioned in my previous article, Americans are woefully deficient in fiber, getting between eight and 15 grams per day, when they should be ingesting more than 40 grams daily. 

In order to increase our daily intake, several myths need to be dispelled. First, fiber does more than improve bowel movements. Also, fiber doesn’t have to be unpleasant. 

The attitude has long been that to get enough fiber, one needs to eat a cardboard box. With certain sugary cereals, you may be better off eating the box, but on the whole, this is not true. Though fiber comes in supplement form, most of your daily intake should be from diet. It is actually relatively painless to get enough fiber; you just have to become aware of which foods are fiber rich.

Fiber has very powerful effects on our overall health. A very large prospective cohort study showed that fiber may increase longevity by decreasing mortality from cardiovascular disease, respiratory diseases and other infectious diseases (1). Over a nine-year period, those who ate the most fiber, in the highest quintile group, were 22 percent less likely to die than those in lowest group. Patients who consumed the most fiber also saw a significant decrease in mortality from cardiovascular disease, respiratory diseases and infectious diseases. The authors of the study believe that it may be the anti-inflammatory and anti-oxidant effects of whole grains that are responsible for the positive results. 

Along the same lines of the respiratory findings, we see benefit with prevention of chronic obstructive pulmonary disease (COPD) with fiber in a relatively large epidemiologic analysis of the Atherosclerosis Risk in Communities study (2). The specific source of fiber was important. Fruit had the most significant effect on preventing COPD, with a 28 percent reduction in risk. Cereal fiber also had a substantial effect but not as great.

Does the type of fiber make a difference? One of the complexities is that there are a number of different classifications of fiber, from soluble to viscous to fermentable. Within each of the types, there are subtypes of fiber. Not all fiber sources are equal. Some are more effective in preventing or treating certain diseases. Take, for instance, a February 2004 irritable bowel syndrome (IBS) study (3). 

It was a meta-analysis (a review of multiple studies) study using 17 randomized controlled trials with results showing that soluble psyllium improved symptoms in patients significantly more than insoluble bran.

Fiber also has powerful effects on breast cancer treatment. In a study published in the American Journal of Clinical Nutrition, soluble fiber had a significant impact on breast cancer risk reduction in estrogen negative women (4). Most beneficial studies for breast cancer have shown results in estrogen receptor positive women. This is one of the few studies that has illustrated significant results in estrogen receptor negative women. 

The list of chronic diseases and disorders that fiber prevents and/or treats also includes cardiovascular disease, Type 2 diabetes, colorectal cancer, diverticulosis and weight gain. This is hardly an exhaustive list. I am trying to impress upon you the importance of increasing fiber in your diet.

Foods that are high in fiber are part of a plant-rich diet. They are whole grains, fruits, vegetables, beans, legumes, nuts and seeds. Overall, beans, as a group, have the highest amount of fiber. Animal products don’t have fiber. Even more interesting is that fiber is one of the only foods that has no calories, yet helps you feel full. These days, it’s easy to increase your fiber by choosing bean-based pastas. Personally, I prefer those based on lentils. Read the labels, though; you want those that are solely made from lentils without rice added.

If you have a chronic disease, the best fiber sources are most likely disease dependent. However, if you are trying to prevent chronic diseases in general, I would recommend getting fiber from a wide array of sources. Make sure to eat meals that contain substantial amounts of fiber, which has several advantages, such as avoiding processed foods, reducing the risk of chronic disease, satiety and increased energy levels. Certainly, while protein is important, each time you sit down at a meal, rather than asking how much protein is in it, you now know to ask how much fiber is in it. 

References:

(1) Arch Intern Med. 2011;171(12):1061-1068. (2) Amer J Epidemiology 2008;167(5):570-578. (3) Aliment Pharmacology and Therapeutics 2004;19(3):245-251. (4) Amer J Clinical Nutrition 2009;90(3):664–671. 

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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Preventing diabetes, cancer and stroke

By David Dunaief, M.D.

Dr. David Dunaief

What better way than a season centered around eating al fresco to kick-start you on the path to preventing chronic diseases? In the past, I have written about the dangers of processed meats in terms of causing chronic diseases, such as cancer, diabetes, heart disease and stroke. These are foods commonly found at barbecues and picnic meals. Therefore, I think it is only fair to talk about healthier alternatives and the evidence-based medicine that supports their benefits.

The Mediterranean-style diet is the key to success. It is composed of thousands of beneficial nutrients that interact with each other in a synergistic way. This particular diet, as I have mentioned in previous articles, includes fish, green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of olive oil. We all want to be healthier, but doesn’t healthy mean tasteless? Not necessarily.

At a memorable family barbecue, we had a bevy of choices that were absolutely succulent. These included a three-bean salad, mandarin orange salad with raspberry vinaigrette, ratatouille with eggplant and zucchini, salmon filets baked with mustard and slivered almonds, roasted corn on the cob, roasted vegetable and scallop shish kebobs and a large bowl of melons and berries. I am drooling at the memory of this buffet. Let’s look at the scientific evidence.

Cancer studies

Fruits and vegetables may help prevent pancreatic cancer. This is very important, since by the time there are symptoms, the cancer has spread to other organs and the patient usually has less than 2.7 years to live (1). Five-year survival is only 5 percent (2). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and noncitrus fruits showed an even more impressive 59 percent reduction in risk of pancreatic cancer (3). Interestingly, cooked vegetables, not just raw ones, had a substantial effect. 

Garlic plays an important role in reducing the risk of colon cancer. In the IOWA Women’s Health Study, a large prospective (forward-looking) trial involving 41,837 women, there was a 32 percent reduction in risk of colon cancer for the highest intake of garlic compared to the lowest. Vegetables also showed a statistically significant reduction in the disease as well (4). Many of my patients find that fresh garlic provides a wonderful flavor when cooking vegetables.

Diabetes studies — treatment and prevention

Fish plays an important role in reducing the risk of diabetes. In a large prospective study that followed Japanese men for five years, those in the highest quartile of intake of fish and seafood had a substanttial decrease in risk of Type 2 diabetes (5). Smaller fish, such as mackerel and sardines, had a slightly greater effect than large fish and seafood in potentially preventing the disease. Therefore, there is nothing wrong with shrimp on the “barbie” to help protect you from developing diabetes. 

Nuts are beneficial in the treatment of diabetes. In a randomized clinical trial (the gold standard of studies), mixed nuts led to a substantial reduction of hemoglobin A1c, a very important biomarker for sugar levels for the past three months (6). As an added benefit, there was also a significant reduction in LDL, bad cholesterol, which reduced the risk of cardiovascular disease. The nuts used in the study were raw almonds, pistachios, pecans, peanuts, cashews, hazelnuts, walnuts and macadamias. How easy is it to grab a small handful of unsalted raw nuts, about 2 ounces, on a daily basis to help treat diabetes?

Stroke 

Olive oil appears to have a substantial effect in preventing strokes. The Three City study showed that olive oil may have a protective effect against stroke. There was a 41 percent reduction in stroke events in those who used olive oil (7). Study participants, who were followed for a mean of 5.2 years, did not have a history of stroke at the start of the trial. Though these are promising results, I would caution use no more than one tablespoon of olive oil per day, since there are 120 calories in a tablespoon. 

It is not difficult to substitute the valuable Mediterranean-style diet for processed meats or at least add them to the selection. This plant-based diet offers a tremendous number of protective elements in the prevention of many chronic diseases. So this Independence Day and beyond, plan to have on hand some mouth-watering healthy choices.

» A staple of the Mediterranean pantry, beans are a healthy, versatile and super affordable ingredient. Rich in antioxidants, fiber, B vitamins and iron, they are a hearty great alternative to high-fat proteins. Serve guests the following three-bean salad as a side dish at your next summer barbecue or picnic. 

Three-Bean Salad

YIELD: Makes 10 servings

INGREDIENTS:

1 15-ounce can of black beans

1 15-ounce can of red kidney beans

1 15-oounce can of cannellini beans

1 yellow bell pepper, chopped

½ red onion, finely chopped

¼ cup olive oil

2 tablespoons red wine vinegar or to taste

1 clove garlic, minced

1 small bunch cilantro, basil or parsley, chopped

¼ cup dill pickle, diced

¼ cup celery, chopped

Salt and pepper to taste

DIRECTIONS: 

Wash and drain the beans. Transfer to large bowl. Add remaining ingredients, toss well and refrigerate for a few hours before serving.

References:

(1) Nature. 2010;467:1114-1117. (2) Epidemiol Prev Anno 2007;31(Suppl 1). (3) Cancer Causes Control. 2010;21:493-500. (4) Am J Epidemiol. 1994 Jan 1;139(1):1-15. (5) Am J Clin Nutr. 2011 Sep;94(3):884-891. (6) Diabetes Care. 2011 Aug;34(8):1706-1711. (7) Neurology. 2011 Aug 2;77(5):418-425. 

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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Lack of exercise is the dominant risk factor for heart attacks. Stock photo
Over the age of 30, inactivity creates the greatest risk

By David Dunaief, M.D.

Dr. David Dunaief

In last week’s article, I wrote about unusual symptoms that may indicate a myocardial infarction (heart attack) and the importance of knowing these atypical major symptoms beyond chest pain. This is not an easy task. I thought a good follow-up to that article would be one that focused on preventable risk factors.

The good news, as I mentioned previously, is that we have made great strides in reducing mortality from heart attacks. When we compare cardiovascular disease — heart disease and stroke — mortality rates from 1975 to the present, there is a substantial decline of approximately one-quarter. However, if we look at these rates since 1990, the rate of decline has slowed (1).

Plus, one in 10 visits to the emergency room are related to potential heart attack symptoms. Luckily, only 10 to 20 percent of these patients actually are having a heart attack (2). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. The obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. Less obvious risk factors include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, also may help allay the risks.

Let’s look at the evidence.

Obesity

On a board exam in medicine, if smoking is one of the choices with disease risk, you can’t go wrong by choosing it. Well, it appears that the same axiom holds true for obesity. But how substantial a risk factor is obesity? 

In the Copenhagen General Population Study, results showed an increased heart attack risk in obese (BMI >30 kg/m²) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m²) (3). The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Since this was an observational trial, we can only make an association, but if it is true, then there may not be such a thing as a “metabolically healthy” obese patient. Therefore, if you are obese, it is really important to lose weight.

Sedentary lifestyle

If obesity were not enough of a wake-up call, let’s look at another aspect of lifestyle: the impact of being sedentary. An observational study found that activity levels had a surprisingly high impact on heart disease risk (4). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect on women’s heart disease risk. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over the age of 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported and not necessarily measured in a doctor’s office, it may have been underestimated as a risk factor for heart disease. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Gout

When we think of gout, we relate it to kidney stones. But gout increases the risk of heart attacks by 82 percent, according to an observational study (6). Gout tends to affect patients more when they are older, but the risk of heart attack with gout is greater in those who are younger, ages 45 to 69, than in those over 70. What can we do to reduce these risk factors?

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (7).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is the fact that those who increased their fiber after the cardiovascular event had a 31 percent reduction in mortality risk. In this analysis, it seemed that more of the benefit came from fiber found in cereal. The most intriguing part of the study was the dose response. For every 10-g increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of cardiovascular events such as heart attacks (8).

Osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? Well, in a study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack. (5) Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References:

(1) Heart. 1998;81(4):380. (2) JAMA Intern Med. 2014;174(2):241-249. (3) JAMA Intern Med. 2014;174(1):15-22. (4) Br J Sports Med. 2014, May 8. (5) Presented Research: World Congress on OA, 2014. (6) Rheumatology (Oxford). 2013 Dec;52(12):2251-2259. (7) BMJ. 2014;348:g2659.  (8) N Engl J Med. 2000;343(1):16.

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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A heart attack does not always have obvious symptoms. Stock photo
Chest pain is only one indicator

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is the most common chronic disease in America. When we refer to heart disease, it is an umbrella term; heart attacks are one component. Fortunately, the incidence of heart attacks has decreased over the last several decades, as have deaths from heart attacks. However, there are still 720,000 heart attacks every year, and more than two-thirds are first heart attacks (1).

How can we further improve these statistics and save more lives? We can do this by increasing awareness and education about heart attacks. It is a multifaceted approach: recognizing the symptoms and knowing what to do if you think you’re having a heart attack.

If you think someone is having a heart attack, call 911 as quickly as possible and have the patient chew an adult aspirin (325 mg) or four baby aspirins. Note that the Food and Drug Administration does not recommend aspirin for primary prevention of a heart attack. However, the use of aspirin here is for treatment of a potential heart attack, not prevention. It is also very important to know the risk factors and how to potentially modify them.

Heart attack symptoms

The main symptom is chest pain, which most people don’t have trouble recognizing. However, there are a number of other, more subtle, symptoms such as discomfort or pain in the jaw, neck, back, arms and epigastric, or upper abdominal, areas. Others include nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate). One problem is that less than one-third of people know these other major symptoms (2). About 10 percent of patients present with atypical symptoms — without chest pain — according to one study (3).

It is not only difficult for the patient but also for the medical community, especially the emergency room, to determine who is having a heart attack. Fortunately, approximately 80 to 85 percent of chest pain sufferers are not having a heart attack. More likely, they have indigestion, reflux or other non-life-threatening ailments.

There has been a raging debate about whether men and women have different symptoms when it comes to heart attacks. Several studies speak to this topic. Let’s look at the evidence.

Men vs. women

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish prospective (forward-looking) study, after having a heart attack, a significantly greater number of women died in hospital or near-term when compared to men. The women received reperfusion therapy, artery opening treatment that consisted of medications or invasive procedures less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram; they both had what we call ST elevations. This was a study involving approximately 54,000 heart attack patients, with one-third of them being women.

One theory about why women are treated less aggressively when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. Women’s symptoms may include pain in the lower portion of the chest or upper portion of the abdomen and may have significantly less severe pain that could radiate or spread to the arms. But, is this true? Not according to several studies.

In one observational study, results showed that, though there were some subtle differences in chest pain, on the whole, when men and women presented with this main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: The duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The study included approximately 2,500 patients, all of whom had chest pain. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. This was a conspicuous weakness of an otherwise mostly solid study, since age and previous heart attack history are important factors.

Therefore, I thought it apt to present another observational study with a younger population, where there was no significant difference in age; the median age of both men and women was 49. In this GENESIS-PRAXY study, results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings (non-ST elevations), significantly more were women than men. Those who did not have chest pain symptoms may have had some of the following symptoms: back discomfort, weakness, discomfort or pain in the throat, neck, right arm and/or shoulder, flushing, nausea, vomiting and headache.

If the patients did not have chest pain, regardless of sex, the symptoms were, unfortunately, diffuse and nonspecific. The researchers were looking at acute coronary syndrome, which encompasses heart attacks. In this case, independent risk factors for disease not related to chest pain included both tachycardia (rapid heart rate) and being female. The authors concluded that there need to be better ways to calibrate non-chest pain symptoms.Some studies imply that as much as 35 percent of patients do not present with chest pain as their primary complaint (7).

Let’s summarize

So what have we learned about heart attack symptoms? The simplest lessons are that most patients have chest pain, and that both men and women have similar types of chest pain. However, this is where the simplicity stops and the complexity begins. The percentage of patients who present without chest pain seems to vary significantly depending on the study — ranging from less than 10 percent to 35 percent.

Therefore, it is even difficult to quantify the number of non-chest pain heart attacks. This is why it is even more important to be aware of the symptoms. Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. When it comes to heart attacks, suspicion should be based on the same symptoms for both sexes. Therefore, know the symptoms, for it may be your life or a loved one’s that depends on it.

References:

(1) Circulation. 2014;128. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA. 2012;307:813-822.

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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Overuse may lead to serious side effects

By David Dunaief, M.D.

Dr. David Dunaief

Reflux (GERD) disease, sometimes referred to as heartburn, though this is more of a symptom, is one of the most commonly treated diseases. Continuing with that theme, proton pump inhibitors (PPIs), which have become household names, are one of the top-10 drug classes prescribed or taken in the United States. In fact, Centers for Disease Control and Prevention data shows that use has grown precipitously in the 10 years ending in 2010 for those ages 55 to 64, from 9 percent of the population to 16 percent (1). This is a 78 percent increase in the number of prescriptions for these drugs.

In 2010, there were 147 million prescriptions filled for PPIs (2). The class of drugs includes Prevacid (lansoprazole), Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). This growth may not capture the fact that several of these medications are now available over the counter.

I remember when PPIs were touted as having one of the cleanest side effect profiles. This may still be true, if we are using them correctly for reflux disease. They are supposed to be used for the short term. This can range from 7 to 14 days for over-the-counter PPIs to 4 to 8 weeks for prescription PPIs.

Why did we not know that this class of drugs might be associated with chronic kidney disease, dementia, bone fractures and Clostridium difficile (a bacterial infection of the gastrointestinal tract) before they were approved? Well, if you look at the manufacturers’ package inserts for these drugs, the trials, such as for Protonix, were no longer than a year (3), yet we are putting patients on these medications for decades. And the longer people are on them, the more complications arise.

Typical symptoms of reflux are heartburn and/or regurgitation. Atypical symptoms include coughing and throat clearing. But these atypical symptoms may not be as common as you might think. In fact, in one study, coughing and throat clearing taken together only resulted in a very small portion of patients having reflux disease (4). Having one of these two symptoms showed a slightly higher risk of reflux, but very modest.

Let’s look at some of the research.

Though PPIs may increase the risk of a number of complications, keep in mind that none of the data are from randomized controlled trials (RCTs), which are the gold standard of studies, but mostly observational studies that suggest an association, but not a link. Long-term RCTs to determine side effects are prohibitively expensive.

PPI and kidney disease

Recent research has tied proton pump inhibitors to a host of alarming health problems. Stock photo

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (5). All of the patients started the study with normal kidney function based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a modest 17 percent increased risk. The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated a modest, but statistically significant, increased risk of chronic kidney disease.

 But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (6).

PPI and bone fractures

In a meta-analysis (a group of 18 observational studies), results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (8). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year. How much less than a year was not delineated. They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption through the gut. 

PPIs reduce the amount of acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (9).

PPI and dementia

Stock photo

A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (7). These patients were at least age 75. The authors surmise that PPIs may cross the coveted blood-brain barrier and have effects by potentially increasing beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent. 

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk, such as multiple drug use, having diabetes, or patient also having depression or a stroke history. Researchers also did not take into account family history of dementia, high blood pressure or excessive alcohol use, all of which have effects on dementia occurrence.

Need for magnesium

PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (10). Diuretics are water pills that are commonly used in disorders such as high blood pressure, heart failure and swelling.

Another study confirmed these results. In this second study, which was a meta-analysis (a group of nine studies), PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (11). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

The bottom line is even though some PPIs are over-the-counter and some are prescription medications, it is best if you confer with your doctor before starting them. You may not need PPIs, but rather a milder medication referred to as H2 blockers (Zantac, Pepcid). Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (12). If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration: 7 to 14 days, according to the FDA (13), without a doctor’s consult, and 4 to 8 weeks with one. Most of the problems occur with long-term use.

References:

(1) cdc.gov. (2) PLoS Med. 2014;11(9):e1001736. (3) protonix.com. (4) J Clin Gastroenterol. Online Jul 18, 2015. (5) JAMA Intern Med. 2016;176(2). (6) JAMA Intern Med. 2016;176(2):172-174. (7) JAMA Neurol. online Feb 15, 2016. (8) Osteoporos Int. online Oct 13, 2015. (9) Am J Med. 118:778-781. (10) PLoS Med. 2014;11(9):e1001736. (11) Ren Fail. 2015;37(7):1237-1241. (12) Am J Gastroenterol 2015; 110:393–400. (13) fda.gov.

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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Being a couch potato is detrimental to your health. Stock photo
Hint — it’s not only about weight

By David Dunaief, M.D.

Dr. David Dunaief

What causes Type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 12.2 percent of the U.S. population aged 18 or older has Type 2 diabetes, and about 9.4 percent when factoring all ages (1).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars because form is important. Sugar and fruit are not the same with respect to their effects on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of Type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage; however, we are talking about the overall prevalence, which is around 9.4 percent in the U.S., as we noted above.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12-ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. 

Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to municipal efforts to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

The effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — Type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a body mass index of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels. It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have Type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat Type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with articles I’ve written on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

Thus, diabetes is most likely a disease caused by a multitude of factors, including obesity, sedentary lifestyle and visceral fat. The good news is that many of these factors are modifiable. Cinnamon and fruit seem to be two factors that help decrease this risk, as does exercise, of course.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make at least some lifestyle modifications. So America, take an active role.

References:

(1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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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Some seemingly innocent activities can increase risk

By David Dunaief, M.D.

Dr. David Dunaief

Warmer weather is finally upon us, and we now have long, sunny days. However, longer sun exposure does increase the risk of skin cancer. Melanoma is the most serious skin cancer, but fortunately it is not the most common. Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) are more prevalent, in that order. Here, we will focus on these two types.

The incidences of these skin cancers are very difficult to pin down because they are not always reported. However, most of us either know someone who has had these types of skin cancer or have had them ourselves. There were roughly three million people diagnosed with nonmelanoma skin cancer in the U.S. in 2012, with the number of treatments increasing 77 percent from 1994 to 2014 (1). SCC and BCC outcomes diverge, with the former having a higher risk of metastases compared to the latter, which tends to grow much slower (2).

These skin cancers may present in different ways. BCC may have a bump that is pearly, waxy, light-colored or pink or flesh-colored or brown. It may bleed, ooze and crust, but may not heal, and can be sunken in the middle (3). SCC has the appearance of a growing nodule. It may also be scaly or crusty and may have flat reddish patches. It may be a sore that also may not heal. It is found on sun-exposed areas, more commonly the forehead, hands, lower lip and nose (3). Interestingly, SCC develops over years of gradual ultraviolet sun exposure, while BCC develops more like melanoma through intense multiple sporadic burns (4).

The more well-known risks for these types of skin cancer include sun exposure (UV radiation), light skin, age, ethnicity and tanning beds (2). But there are other risk factors, such as manicures. There are also ways to reduce risk with sunscreen reapplied every two hours, depending on what you are doing, but also NSAIDs (nonsteroidal anti-inflammatory drugs) and even vitamin B3. Let’s look at the research.

Ultraviolet radiation from the sun or tanning beds can cause skin cancer. Stock photo

 

Risks of other cancers

Though nonmelanoma skin cancers (NMSCs) have far less potential to be deadly, compared to melanoma, there are other risks associated with them. In the CLUE II cohort study of over 19,000 participants, results show something very disturbing: A personal history of NMSC can lead to other types of cancer throughout the body (5). The increased risk of another type of cancer beyond NMSC is 103 percent in those with BCC and 97 percent in those with SCC, both compared to those who did not have a personal history of NMSC.

Tanning beds — No surprise

We know that tanning beds may be a cause for concern. Now the FDA has changed the classification of tanning beds from low to moderate risk and requires a warning that they should not be used by those under the age of 18 (6). Some states have more restrictive laws, banning tanning bed use or requiring parental consent when teens are below certain ages. Compliance with these laws varies.

However, in a prospective (forward-looking) study, results show that people’s responses to warnings depended on how the warnings were framed (7). Compared to the text-only FDA warning requirement, graphic warnings that emphasized the risks of skin cancer were more likely to help people stop using tanning beds, whereas graphic warnings that demonstrated the positive benefits of not using these devices had no effects. So you may have to scare the daylights out of those in their teens and early twenties.

Manicure risk, really?

I am told women and some men love manicures. Manicures cannot possibly be dangerous, right? Not so fast. It is not the actual manicure itself, but rather the drying process that poses a risk. In a prospective study, results show that drying lamps used after a manicure may increase the risk of DNA damage to the skin, which could lead to skin cancer, though the risk is small per visit (8).

There were a lot of variables. The shortest number of visits to increase the risk of skin cancer was eight, but the intensity of the UVA irradiance varied considerably in 17 different salons. The median number of months it took to have carcinogenic potential with exposure was around 35, or roughly three years. The authors recommend either gloves or suntan lotion when using these devices, although both seem to be somewhat impractical with wet nails. It’s best to let your nails dry naturally.

Vitamin B3 to the rescue

Many vitamins tend to disappoint when it comes to prevention. Well, hold on to your hat. This may not be the case for vitamin B3. In the Australian ONTRAC study, the results showed that vitamin B3 reduced the risk of developing NMSC by 23 percent, compared to those who took a placebo (9). Even better was the fact that SCC was reduced by 30 percent.

The most interesting part about this study is that these results were in high-risk individuals who had a personal history of NMSC. The participants were given B3 (nicotinamide 500 mg) twice daily for one year.

After the patients discontinued taking B3, the benefits dissipated within six months. The study was on the small side, including 386 patients with two or more skin cancer lesions in the last five years, with a mean of eight lesions. The side effects were minimal and did not include the flushing (usually neck and facial redness) or headaches seen with higher levels of niacin, another derivative. The caveat is that this study was done in Australia, which has more intense sunlight. We need to repeat the study in the U.S. Nicotinamide is not expensive, and it has few side effects.

NSAIDs as beneficial?

Results have been mixed previously in terms of NSAIDs and skin cancer prevention. However, a more recent meta-analysis (nine studies of varying quality, with six studies considered higher quality) showed that especially nonaspirin NSAIDs reduced the risk of SCC by 15 percent compared to those who did not use them (10).

Diet — The good and the bad

In terms of diet studies, there have been mixed positive and neutral results, especially when it comes to low-fat diets. These are notoriously difficult to run because the low-fat group rarely remains low fat. However, in a prospective dietary study, results showed that effects on skin cancer varied depending on the foods. For those who were in the highest tertile of meat and fat consumption, compared to those in the lowest tertile, there was a threefold increased risk of a squamous cell cancer in those who had a personal history of SCC (11). But what is even more interesting is that those who were in the highest tertile of vegetable consumption, especially green leafy vegetables, experienced a 54 percent reduction in skin cancer, compared to those in the lowest consumption tertile.

Thus, know that there are modifiable risk factors that reduce the risk of nonmelanoma skin cancer and don’t negatively impact your enjoyment of summer. There may be easy solutions to help prevent recurrent skin cancer, as well, that involve both medication and lifestyle modifications.

References:

(1) skincancer.org. (2) uptodate.com. (3) nih.gov. (4) Br J Cancer. 2006;94(5):743. (5) J Natl Cancer Inst. 2008;100(17):1215-1222. (6) federalregister.gov. (7) Am J Public Health. Online June 11, 2015. (8) JAMA Dermatol. 2014;150(7):775-776. (9) ASCO 2015 Annual Meeting: Abstract 9000. (10) J Invest Dermatol. 2015;135(4):975-983. (11) Am J Clin Nutr. 2007;85(5):1401.

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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TIAs are a serious warning sign of stroke and should not be ignored.
Ministrokes are not inconsequential

By David Dunaief, M.D.

Dr. David Dunaief

A TIA (transient ischemic attack) is sometimes referred to as a ministroke. This is a disservice since it makes a TIA sound like something that should be taken lightly. Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot across the bow that needs to be taken very seriously on its own merit. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (1). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. I have helped manage patients with symptoms as understated as the onset of double vision. Other symptoms may include facial or limb weakness on one side, slurred speech or problems comprehending others, dizziness or difficulty balancing or blindness in one or both eyes (2). TIA incidence increases with age (3).

What is a TIA?

TIAs are a serious warning sign of stroke and should not be ignored.

The definition has changed over time from one purely based on time (less than one hour), to differentiate it from a stroke, to one that is tissue based. It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia (low blood flow in the back of the eye) without evidence of acute infarction (tissue death) (4). In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, creating difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Why take a TIA seriously if its debilitating effects are temporary? 

Though they are temporary, TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death. Despite the seriousness of TIAs, patients or caregivers often delay receiving treatment.

Stroke risk

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (5). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (6). Even worse, over the long term, the probability that a patient will experience a stroke reaches approximately 30 percent, one in three, after five years (7).

To go even further, there was a study that looked at the immediacy of treatment. The EXPRESS study, a population-based study that considered the effect of urgent treatment of TIA and minor stroke on recurrent stroke, evaluated 1,287 patients, comparing their initial treatment times after experiencing a TIA or minor stroke and their subsequent outcomes (8).

The Phase 1 cohort was assessed within a median of three days of symptoms and received a first prescription within 20 days. In Phase 2, median delays for assessment and first prescription were less than one day. All patients were followed for two years after treatment. Phase 2 patients had significantly improved outcomes over the Phase 1 patients. Ninety-day stroke risk was reduced from 10 to 2 percent, an 80 percent improvement.

The study’s authors advocate for the creation of TIA clinics that are equipped to diagnose and treat TIA patients to increase the likelihood of early evaluation and treatment and decrease the likelihood of a stroke within 90 days. The moral of the story is: Treat a TIA as a stroke should be treated, the faster the diagnosis and treatment, the lower the likelihood of sequela, or complications.

Predicting the risk of stroke complications

Both DWI (diffusion weighted imaging) and ABCD2 are potentially valuable predictors of stroke after TIA. The ABCD2 is a clinical tool used by physicians. ABCD2 stands for Age, Blood pressure, Clinical features and Diabetes, and it uses a scoring system from 0 to 7 to predict the risk of a stroke within the first two days of a TIA (9).

Heart attack

In one epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (10). These were patients without known heart disease. Interestingly, the risk of heart attacks was much higher in those over 60 years of age and continued for years after the event. Just because you may not have had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack. Even patients taking statins to lower cholesterol were at higher risk of heart attack after a TIA.

Mortality

If stroke and heart attack were not enough, TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years and by 20 percent after nine years, especially in those over age 65, according to a study published in Stroke (11). The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort (particular group of patients) study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (12). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (13). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include a Mediterranean and DASH diet combination. Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

In researching information for this article, I realized that there are not many separate studies for TIA; they are usually clumped with stroke studies. This underscores the seriousness of this malady. If you or someone you know has TIA symptoms, the patient needs to see a neurologist and a primary care physician and/or a cardiologist immediately for assessment and treatment to reduce risk of stroke and other long-term effects.

References:

(1) Stroke. Apr 2005;36(4):720-723; Neurology. May 13 2003;60(9):1429-1434. (2) mayoclinic.org. (3) Stroke. Apr 2005;36(4):720-723. (4) N Engl J Med. Nov 21 2002;347(21):1713-1716. (5) Neurology. 2011 Sept 27; 77:1222. (6) Lancet Neurol. Dec 2007;6(12):1063-1072. (7) Albers et al., 1999. (8) Stroke. 2008;39:2400-2401. (9) Lancet. 2007;9558;398:283-292. (10) Stroke. 2011; 42:935-940. (11) Stroke. 2012 Jan;43(1):79-85. (12) Stroke. 2011 Jul;42(7):1857-1861. (13) JAMA. 2005 Mar 23;293(12):1435.

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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