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Our genes are not destiny. METRO photo

By David Dunaief, M.D.

Heart disease risk is influenced by family history and by lifestyle, including diet. But what if we could tackle genetic issues with diet?

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

The role of genes in heart disease

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It aligns with what we see in modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, such as with a plant-rich diet, such as a Mediterranean-type diet.

Does diet affect our genetic response?

A New England Journal of Medicine study explores the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet, with participants randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, risk improvement in the Mediterranean-type diet arms occurred even though there was no significant weight loss.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The Mediterranean-type diet arms both included significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence,” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two opposing opinions, split by field. You may be surprised by which group liked it and which did not.

Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring meaningful clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more people, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

So, what have we learned? Even with a genetic propensity for cardiovascular disease, we can alter our cardiovascular destinies with diet.

References:

(1)www.uptodate.com (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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

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Pexels photo

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease gets a lot of attention, because it’s still the number one cause of death in the U.S. We know that diet plays a significant role in this, but so do our genes.

What if we could tackle genetic issues with diet? 

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

The role of genes

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It aligns with what we see in modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that this study does not support that. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, such as with a plant-rich diet, such as a Mediterranean-type diet.

Can we improve our genetic response with diet?

The New England Journal of Medicine published study about the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, the risk profile improvement occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence,” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two opposing opinions, split by field. You may be surprised by which group liked it and which did not.

Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

So, what have we learned? Even with a genetic proclivity toward cardiovascular disease, we can alter our cardiovascular destinies.

References: 

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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

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Mediterranean diet. Pexels photo
Diet plays a large role in quality of life as we age

By David Dunaief, M.D.

Dr. David Dunaief

What if I told you that approximately 85 percent of the U.S. population is malnourished, regardless of socioeconomic status and, in many cases, despite being overweight or obese (1)? The definition of malnourished is insufficient nutrition, which in the U.S. results from low levels of much-needed nutrients. Sadly, the standard American diet is very low in nutrients, so many have at least moderate malnutrition.

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

Here’s a stunning statistic: more than 50 percent of American adults have a chronic disease, with 27 percent having more than one (2). This is likely a factor in the slowing pace of life expectancy increases in the U.S., which have plateaued in the past decade and are currently at around 77 years old.

I regularly test patients’ carotenoid levels. Carotenoids are nutrients that are incredibly important for tissue and organ health. They are measurable and give the practitioner a sense of whether the patient may lack potentially disease-fighting nutrients. A high nutrient intake dietary approach can resolve the situation and increase, among others, carotenoid levels.

Benefits of high nutrient intake

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

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

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

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

Improving quality of life

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

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

In a case-control study that compared those with and without disease, high intake of antioxidants from food was associated with a significant decrease in the risk of early Age-related Macular Degeneration (AMD), even when participants had a genetic predisposition for the disease (6). AMD is the leading cause of blindness in those 55 years or older.

There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA- substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

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

References: 

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

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

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METRO photo
Which diet has better cardiovascular outcomes?

By David Dunaief, M.D.

Dr. David Dunaief

Despite the great strides we have made in the fight against heart disease, it is still the number one cause of death in the United States. Can we alter this course, or is it our destiny?

A study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce our risk factors with lifestyle adjustments.

 Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

Do our genes matter?

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It seems to coordinate with modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that this study does not support that. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, potentially by following a plant-rich diet, such as a Mediterranean-type diet.

Can we improve our genetic response with diet?

The New England Journal of Medicine published a study about the Mediterranean-type diet and its potential impact on cardiovascular disease risk (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, compared to the low-fat diet. Study end points included heart attacks, strokes and mortality. Interestingly, the risk profile improvement occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and wine. I call them “Mediterranean diets with opulence” because both groups consuming this diet had either significant amounts of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day), and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two diametrically opposed opinions, split by field. You may be surprised by which group liked it and which did not. Cardiologists, including well-known physicians Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D., former chairman of cardiovascular medicine at Cleveland Clinic, hailed the study as a great achievement. This group of physicians emphasized that now there is a large, randomized trial measuring clinical outcomes, such as heart attacks, stroke and death. 

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So, who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more focused diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

Ultimately, even with a genetic proclivity toward cardiovascular disease, we have confirmation that we can alter our cardiovascular destinies. The degree depends on the willingness of the participants.

References:

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

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

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METRO photo
Mouthwatering barbeque options can decrease health risks

By Daniel Dunaief

Dr. David Dunaief

What better way than the unofficial launch of summer holidays – and summer barbeques – 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 barbeques 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 a key to success. It is composed of thousands of beneficial nutrients that interact with each other in synergistic ways. 

The Mediterranean-style diet, as I have mentioned previous articles, includes green leafy vegetables, fruit, nuts and seeds, beans and legumes, whole grains and small amounts of fish and olive oil. We all want to be healthier, but these are the summer holidays – doesn’t healthy mean tasteless? Not at all!

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

Cancer prevention

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 five percent (2). In a case control (epidemiological observational) study, cooked vegetables showed a 43 percent reduction and non-citrus 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. Vegetable consumption 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 – 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 substantial 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 some grilled fish 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 previous 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 prevention

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 caution you to 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.

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):1706-11. (7) Neurology. 2011 Aug 2;77(5):418-25.

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

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Switching to a Mediterranean diet will help treat elevated blood pressure. Metro Photo
Treating early with lifestyle changes can improve your long-term outcomes

By David Dunaief, M.D.

Dr. David Dunaief

We have focused a large amount of effort on the treatment and prevention of hypertension (high blood pressure) in the U.S, where it’s pervasive: it affects approximately 45 percent of adults over 18 in the U.S. (1).

Since 2017, this insidious disorder’s severity has been categorized into three stages, each with its recommended treatment regimen. One of the most interesting shifts with this recategorization was the recategorization of what we used to call “prehypertension” into what we now call “elevated” blood pressure and “hypertension stage 1.” 

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg, while Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of less than 80-89 mmHg (2).

The consequences of both are significant, even though there are often no symptoms. For example, they increase the risk of cardiovascular disease and heart attack dramatically. In an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (3). This is why it’s crucial to treat it in these early stages, even before it reaches the more severe levels of hypertension.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (4).

This may or may not impact mortality, but it certainly does impact quality of life, which can be dramatically reduced with heart disease, heart attack and hypertension.

Elevated blood pressure treatment

In my view, it would be foolish not to treat elevated blood pressure. Updated recommendations for treatment, according to the Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, are lifestyle modifications (5).

Lifestyle changes include a Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet. It’s important to focus on fruits, vegetables, reduction in sodium to a maximum of 1500 mg (2/3 of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (6). Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (7). 

Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

The danger in treating elevated blood pressure comes only when medication is used, due to side effects. For example, the Trial of Preventing Hypertension (TROPHY), suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (8)(9). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Still, the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, the makers of the drug. 

In an editorial, Jay I. Meltze, M.D., a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (10). 

Elevated blood pressure is an asymptomatic disorder that has been shown to respond well to lifestyle changes — why create symptoms with medication? Therefore, I don’t recommend treating elevated blood pressure patients with medication. Thankfully, the JNC8 agrees.

However, it should be treated — and treated with lifestyle modifications. The side effects from this approach are only better overall health.

References:

(1) cdc.gov. (2) heart.org. (3) Stroke 2005; 36: 1859–1863. (4) Hypertension 2006;47:410-414. (5) Am Fam Physician. 2014 Oct 1;90(7):503-504. (6) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (7) Archives of Internal Medicine 2001;161:589-593. (8) N Engl J Med. 2006;354:1685-1697. (9) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (10) Am J Hypertens. 2006;19:1098-1100.

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

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In recent studies, the Mediterranean-type diet decreased mortality significantly. Stock photo
Many Americans are malnourished

By David Dunaief, M.D.

Dr. David Dunaief

It may come as a surprise, but most of us are malnourished. How could that be, when approximately 70 percent of the U.S. population is overweight or obese? When we think of malnourishment, developing countries come to mind. However, malnourishment is not directly correlated with hunger; it is common at all levels of the socioeconomic scale. The definition of malnourished is insufficient nutrition, which in the U.S. results from low levels of much needed nutrients.

Over the last 30 years, the pace of increase in life expectancy has slowed substantially. In fact, a New England Journal of Medicine article noted that life expectancy may actually decline in the near future (1). 

According to the American Medical Association, almost half of Americans have at least one chronic disease, with 13 percent having more than three (2). The projection is that 157 million Americans will have more than one chronic disease by 2020. Most chronic diseases, including common killers, such as heart disease, stroke, diabetes and some cancers, can potentially be prevented, modified and even reversed with a focus on nutrients, according to the Centers for Disease Control and Prevention (CDC). 

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

What is a high nutrient intake and why is it so important?

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

Let’s look at some examples.

A study showed olive oil reduces the risk of stroke by 41 percent (3). The authors attribute this effect at least partially to oleic acid, a bioactive compound found in olive oil. While olive oil is important, I recommend limiting olive oil to one tablespoon a day. There are 120 calories per tablespoon of olive oil, all of them fat. If you eat too much, even of good fat, it defeats the purpose. The authors commented that the Mediterranean-type diet had only recently been used in trials with neurologic diseases and results suggest benefits in several disorders, such as Alzheimer’s. 

In a case-control (compare those with and without disease) study, high intake of antioxidants from food is associated with a significant decrease in the risk of early age-related macular degeneration (AMD), even when participants had a genetic predisposition for the disease (4). AMD is the leading cause of blindness in those 55 years or older. There were 2,167 people enrolled in the study with several different genetic variations that made them high risk for AMD. Those with a highest nutrient intake, including B-carotene, zinc, lutein, zeaxanthin, EPA and DHA, substances found in fish, had an inverse relationship with risk of early AMD. Nutrients, thus, may play a role in modifying gene expression. 

What can we do to improve life expectancy?

In the Greek EPIC trial, a large prospective (forward-looking) cohort study, the Mediterranean-type diet decreased mortality significantly — the better the compliance, the greater the effect (5). 

The most powerful dietary components were the fruits, vegetables, nuts, olive oil, legumes and moderate alcohol intake. Low consumption of meat also contributed to the beneficial effects. Dairy and cereals had a neutral or minimal effect.

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

References:

(1) N Engl J Med 2005; 352:1138-1145. (2) www.ama-assn.org. (3) Neurology June 15, 2011. (4) Arch Ophthalmol. 2011;129(6):758-766. (5) BMJ. 2009;338:b2337.

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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Different types of exercise have different impacts

By David Dunaief, M.D.

Dr. David Dunaief

Mild cognitive impairment (MCI) is one of the more common disorders that occurs as we age. But age is not the only determinant. There are a number of modifiable risk factors. MCI is feared, not only for its own challenges but also because it may lead to dementia, with Alzheimer’s disease and vascular dementia being the more common forms. Prevalence of MCI may be as high as one-in-five in those over age 70 (1). It is thought that those with MCI may have a 10 percent chance of developing Alzheimer’s disease (2).

Since there are very few medications presently that help prevent cognitive decline, the most compelling questions are: What increases risk and what can we do to minimize the risk of developing cognitive impairment? These are the important questions.

Many chronic diseases and disorders contribute to MCI risk. These include diabetes, heart disease, Parkinson’s disease and strokes. If we can control these maladies, we may reduce the risk of cognitive decline. This involves making lifestyle modifications such as exercise and diet. We know that we can’t stop aging, but we can age gracefully.

Heart disease’s impact

Although we have made great strides, heart disease continues to be prevalent in America. In an observational study, results demonstrated that those suffering from years of heart disease are at a substantial risk of developing MCI (3). The study involved 1,450 participants who were between the ages of 70 and 89 and were not afflicted by cognitive decline at the beginning of the study. Patients with a history of cardiac disease had an almost two times greater risk of developing nonamnestic MCI, compared to those individuals without cardiac disease. Women with cardiac disease were affected even more, with a three times increased risk of cognitive impairment.

Nonamnestic MCI affects executive functioning — decision-making abilities, spatial relations, problem-solving capabilities, judgments and language. It is a more subtle form of impairment that may be more frustrating because of its subtlety. It may lead to vascular dementia and may be a result of clots. This gives us yet another reason to treat and prevent cardiac disease.

Stroke location vs. frequency

Not surprisingly, stroke may have a role in cognitive impairment. Stroke is also referred to as a type of vascular brain injury. But what is surprising is that in a study, results showed that the location of the stroke was more relevant than the frequency or the multitude of strokes (4). If strokes occurred in the cortical and subcortical gray matter regions of the brain, executive functioning and memory were affected, respectively. Thus, the locations of strokes may be better predictors of subsequent cognitive decline than the number of strokes. Clinically silent strokes that were found incidentally by MRI scans had no direct effect on cognition, according to the authors.

Exercise’s effects

Studies have shown that aerobic exercise improves brain function. Stock photo

Exercise may play a significant role in potentially preventing cognitive decline and possibly even improving MCI in patients who have the disorder. Interestingly, different types of exercise have different effects on the brain. Aerobic exercise may stimulate one type of neuronal development, while resistance training or weight lifting another.

In an animal study involving rats, researchers compared aerobic exercise to weight lifting (5). Weight lifting was simulated by attaching weights to the tails of rats while they climbed ladders. Both groups showed improvements in memory tests, however, there was an interesting divergence.

With aerobic exercise, the level of the protein BDNF (brain-derived neurotrophic factor) increased significantly. This is important, because BDNF is involved in neurons and the connections among them, called synapses, related mostly to the hippocampus, or memory center. The rats that “lifted weights” had an increase in another protein, IGF (insulin growth factor), that promotes the development of neurons in a different area of the brain. The authors stressed the most important thing is to exercise, regardless of the type.

In another study that complements the previous study, women were found to have improved spatial memory when they exercised — either aerobic or weight lifting (6). Interestingly, verbal memory was improved more by aerobic exercise than by weight lifting. Spatial memory is the ability to recall where items were arranged, and verbal memory is the ability to recall words. The authors suggest that aerobic exercise and weight lifting affect different parts of the brain, which corroborates the animal study findings above.

This was a randomized controlled trial that was six months in duration and involved women, ages 70 to 80, who had MCI at the trial’s start. There were three groups in the study: aerobic, weight lifting and stretching and toning. Those who did stretches or toning alone experienced deterioration in memory skills over the same period.

Here is the catch with exercise: We know exercise is valuable in preventing disorders like cardiovascular disease and cognitive decline, but are Americans doing enough? A Centers for Disease Control and Prevention report claims the majority of the adult population is woefully deficient in exercise: Only about 1 in 5 Americans exercise regularly, both using weights and doing aerobic exercise (7).

Diet’s effects

Several studies show that the Mediterranean diet helps prevent MCI and possibly prevents conversion from MCI to Alzheimer’s (8, 9). In addition, a study showed that high levels of carbohydrates and sugars, when compared to lower levels, increased the risk of cognitive decline by more than three times (5). The authors surmise that carbohydrates have a negative impact on insulin and glucose utilization in the brain.

Cognitive decline is a disorder that should be taken very seriously, and everything that can be done to prevent it should be utilized. Though the number of Americans exercising regularly is woefully deficient, the silver lining is that there is substantial room for improvement. Exercise has potentially positive effects on neuron growth and development. We need more campaigns like the NFL’s Play 60, which entices children to be active at least 60 minutes every day, but we also need to target adults of all ages. Let’s not squander the opportunity to reduce the risk of MCI, a potentially life-altering disorder.

References: (1) Ann Intern Med. 2008;148:427-434. (2) uptodate.com. (3) JAMA Neurol. 2013;70:374-382. (4) JAMA Neurol. 2013;70:488-495. (5) J Alzheimers Dis. 2012;32:329-339. (6) J Aging Res. 2013;2013:861893. (7) Morb Mortal Wkly Rep. 2013;62:326-330. (8) Neurology 2013;80:1684-1692. (9) Arch Neurol. 2009 Feb.;66:216-225.

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 recent study showed that patients who are very obese could lose almost two decades of healthy living
Quality of life impacts are considerable

By David Dunaief, M.D.,

Dr. David Dunaief

The media is increasingly focused on covering obesity-related issues. With this in mind, let’s start off with a short quiz to test your knowledge of obesity-related issues. The answers and research are provided below. Regardless of your quiz score, it is important to understand the research.

1. Obesity reduces life span by up to:

A) Not at all

B) 4 years

C) 8 years

D) 10 years

2. Obesity shortens healthy years of life by:

A) 8 years

B) 12 years

C) 15 years

D) 20 years

3. Food cravings can be reduced for the short term by:

A) Counting to 20

B) Tapping your finger against your head

C) Watching TV

D) Texting on your cellphone

4. Obesity can lead to the following complication(s):

A) High blood pressure

B) Diabetes

C) Cancer

D) All of the above

Are you eager to find out the answers? I hope so, because there are some very salient points I am trying to make by providing multiple choice questions. The answers are: 1. D; 2. D; 3. B; 4. D. So how did you do? One of the questions was actually similar to a question on a medical website for doctors, so don’t be too hard on yourself if you did not get them all right. Let’s look at the research.

Mortality and effect on life span

Many of you know that obesity could have an impact on development of other chronic diseases and a decrease in quality of life, but to what extent? A 2013 study indicated that almost as many as one in five deaths in the U.S. is associated with obesity (1).

In a computer modeling study, the results showed that those who are obese may lose up to eight years, almost a decade, of their life span (2). But that is only part of the results. The other, more compelling result is that patients who are very obese, defined as a BMI >35 kg/m², could lose almost two decades of healthy living. According to the researchers, this means you may have diseases such as diabetes and cardiovascular disease. However, even those patients who were obese and those who were overweight also could have reductions in life span, up to 6 years and 3 years, respectively.

There were 3,992 adults between the ages of 20 and 79 evaluated in this study. The data was taken from an NHANES database from 2003 to 2010, which looked at participants who went on to develop diabetes and cardiovascular disease. Though this is not a clinical trial, and there is a need for more study, the results are eye-opening, with the youngest and very obese negatively impacted the most.

Cancer impact

Since it is very difficult to “cure” cancer, although hopefully someday soon we will, it is important to reduce modifiable risk factors. Obesity may be one of these contributing factors, although it is hotly debatable how much of an impact obesity has on cancer development.  The American Society of Clinical Oncologists (ASCO), in a position paper, supported the idea that it is important to treat obesity in the fight against cancer (3). The authors indicate obesity may make the prognosis worse, may hinder the delivery of therapies to treat cancer, and may increase the risk of malignancy.

Also, possibly reinforcing ASCO’s stance, a study suggested that upward of a half-million cases of cancer worldwide were related to being overweight or obese, with the overwhelming concentration in North American and Europe (4).

Possible solutions

A potential counterweight to both the reductions in life quality and life expectancy may be the Mediterranean diet. In a published analysis of the Nurses’ Health Study, results show that the Mediterranean diet helped slow shortening of the telomeres (5). Repeat sequences of DNA found at the end of chromosomes, telomeres, shorten with age; the shorter the telomere, the shorter life expectancy.

Thus, the Mediterranean diet may decrease occurrence of chronic diseases, increase life span and decrease premature mortality — hence, the opposite effect of obesity. In fact, it may help treat obesity, though this was not mentioned in the study. Interestingly, the effects of the Mediterranean diet were on a dose-response curve. The greater the adherence to the diet, rated on a scale of 0 to 9, the better the effect. Those who had an increase in adherence by three points saw a corresponding decrease in telomere aging by 4.5 years. There were 4,676 middle-aged women involved in this analysis. The researchers believe that the anti-inflammatory and antioxidant effects could be responsible for the diet’s effects.

According to an accompanying editorial, no individual component of the diet was identified as having beneficial effects by itself, so it may be the diet as a whole that is important (6).

Short-term solutions

There are easy-to-use distraction tactics that involve physical and mental techniques to reduce food cravings. These include tapping your foot on the floor, staring at a blank wall and, yes, alternating tapping your index finger against your forehead and your ear (7). The forehead and ear tapping was most effective, although probably most embarrassing in public. Among mental techniques, seeing pictures of foods that were unhealthy and focusing on their long-term detriments to health had the most impact (8). All of these short-term distractors were done for 30 seconds at a time. The results showed that in obese patients they indeed decreased food cravings.

Exercise impact

I have written about exercise and that it does not lead to fat percentage loss in adults. Well, before you write off exercise for fat loss, it seems that adolescents may benefit from exercise. In a randomized controlled trial, the gold standard of studies, results show that those in the resistance training group alone and those in a combined resistance and aerobic training group had significantly greater percentages of fat loss compared to a control group (9).

However, the aerobic group alone did not show a significant change in fat percent versus the control. There were 304 study participants, ages 14 to 18, followed for a six-month duration, and results were measured with MRI. The reason that resistance training was effective in reducing fat percentage may have to do with an increase in muscle mass rather than a decrease in actual fat. Still, exercise is important. It doesn’t matter if it decreases the fat percentage; it is still getting you to the goal.

Obesity can have devastating effects, from potentially inducing cancer or worsening it, to shortening life expectancy and substantially decreasing quality of life. Fortunately, there may be ways to help treat obesity with specific lifestyle modifications. The Mediterranean diet as a whole may be an effective step toward decreasing the burden of obesity and reducing its complications. Kids, teenagers specifically, should be encouraged to “Play 60,” as the NFL has encouraged, but also to do some resistance training. As we mentioned, there are simple techniques that may help reduce short-term food cravings.

References: (1) Am J Public Health. 2013;103:1895-1901. (2) The Lancet Diabetes & Endocrinology, online Dec. 5, 2014. (3) J Clin Oncol. 2014;32(31):3568-3574. (4) The Lancet Oncology. online Nov. 26, 2014. (5) BMJ. online Dec. 2, 2014. (6) BMJ 2014;349:g6843. (7) Obesity Week 2014 abstract T-2658-P. (8) Obesity Week 2014 abstract T-3023-OR. (9) JAMA Pediatr. 2014;168(11):1006-1014.

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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