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Tag: cholesterol

  • Is Stainless Steel or Cast Iron Cookware Best? Is Teflon Safe? | NutritionFacts.org

    Is Stainless Steel or Cast Iron Cookware Best? Is Teflon Safe? | NutritionFacts.org

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    What is the best type of pots and pans to use?

    In my last video, I expressed concerns about the use of aluminum cookware. So, what’s the best type of pots and pans to use? As I discuss in my video Stainless Steel or Cast Iron: Which Cookware Is Best? Is Teflon Safe?, stainless steel is an excellent option. It’s the metal chosen for use “in applications where safety and hygiene are considered to be of the utmost importance, such as kitchenware.” But what about studies showing that the nickel and chromium in stainless steel, which keeps the iron in stainless unstained by rust, can leach into foods during cooking? The leaching only seems to occur when the cookware is brand new. “Metal leaching decreases with sequential cooking cycles and stabilizes after the sixth cooking cycle,” after the sixth time you cook with it. Under more common day-to-day conditions, the use of stainless steel pots is considered to be safe even for most people who are acutely sensitive to those metals. 

    A little leaching metal can even be a good thing in the case of straight iron, like a cast iron skillet, which can have the “beneficial effect” of helping to improve iron status and potentially reduce the incidence of iron deficiency anemia among children and women of reproductive age. The only caveat is that you don’t want to fry in cast iron. Frying isn’t healthy regardless of cookware type, but, at hot temperatures, vegetable oil can react with the iron to create trans fats. 

    What about using nonstick pans? Teflon, also known as polytetrafluoroethylene (PTFE), “is used as an inner coating material in nonstick cookware.” Teflon’s dark history was the subject of a 2019 movie called Dark Waters, starring Mark Ruffalo and Anne Hathaway. Employees in DuPont’s Teflon division started giving birth to babies with deformities before “DuPont removed all female staff” from the unit. Of course, the corporation buried it all, hiding it from regulators and the public. “Despite this significant history of industry knowledge” about how toxic some of the chemicals used to make Teflon were, it was able to keep it hidden until, eventually, it was forced to settle for more than half a billion dollars after one of the chemicals was linked to “kidney and testicular cancers, pregnancy-induced hypertension, ulcerative colitis, and high cholesterol.”

    “At normal cooking temperatures, PTFE-coated cookware releases various gases and chemicals that present mild to severe toxicity.” As you can see below and at 2:38 in my video, different gases are released at different temperatures, and their toxic effects have been documented. 

    You’ve heard of “canaries in the coal mine”? This is more like “canaries in the kitchen, as cooking with Teflon cookware is well known to kill pet birds,” and Teflon-coated heat lamp bulbs can wipe out half a flock of chickens. 

    “Apart from the gases released during heating the cooking pans, the coating itself starts damaging after a certain period. It is normally advised to use slow heating when cooking in Teflon-coated pans,” but you can imagine how consumers might ignore that. And, if you aren’t careful, some of the Teflon can start chipping off and make its way into the food, though the effects of ingestion are unknown.

    I could find only one study that looks at the potential human health effects of cooking with nonstick pots and pans. Researchers found that the use of nonstick cookware was associated with about a 50 percent increased risk of colorectal cancer, but that may be because of what they were cooking. “Non-stick cookware is used in hazardous cooking methods (i.e. broiling, frying, grilling or barbecuing) at high temperatures mainly for meat, poultry or fish,” in which carcinogenic heterocyclic amines (HCA) are formed from the animal protein. Then, the animal fat can produce another class of carcinogens called polycyclic aromatic hydrocarbons (PAH). Though it’s possible it was the Teflon itself, which contains suspected carcinogens like that C8 compound from the movie Dark Waters, also known as PFOA, perfluorooctanoic acid.

    “Due to toxicity concerns, PFOA has been replaced with other chemicals such as GenX, but these new alternatives are also suspected to have similar toxicity.” We’ve already so contaminated the Earth with it, though, that we can get it prepackaged in food before it’s even cooked, particularly in dairy products, fish, and other meat; now, “meat is the main source of human exposure” to these toxic pollutants. Of those, seafood is the worst. In a study of diets from around the world, fish and other seafood were “major contributors” of the perfluoroalkyl substances, as expected, given that everything eventually flows into the sea. Though the aquatic food chain is the “primary transfer mechanism” for these toxins into the human diet, “food stored or prepared in greaseproof packaging materials,” like microwave popcorn, may also be a source. 

    In 2019, Oral-B Glide dental floss was tested. Six out of 18 dental floss products researchers tested showed evidence of Teflon-type compounds. Did those who used those kinds of floss end up with higher levels in their bloodstream? Yes, apparently so. Higher levels of perfluorohexanesulfonic acid were found in Oral-B Glide flossers, as you can see below and at 5:28 in my video.

    There are a lot of environmental exposures in the modern world we can’t avoid, but we shouldn’t make things worse by adding them to consumer products. At least we have some power to “lower [our] personal exposure to these harmful chemicals.”

    This is the second in a three-video series on cookware. The first was Are Aluminum Pots, Bottles, and Foil Safe?, and the next is Are Melamine Dishes and Polyamide Plastic Utensils Safe?.

    What about pressure cooking? I covered that in Does Pressure Cooking Preserve Nutrients?.

    So, what is the safest way to prepare meat? See Carcinogens in Meat. 

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    Michael Greger M.D. FACLM

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  • Testing for Vitamin B12 Deficiency  | NutritionFacts.org

    Testing for Vitamin B12 Deficiency  | NutritionFacts.org

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    Many doctors mistakenly rely on serum B12 levels in the blood to test for vitamin B12 deficiency.

    There were two cases of young, strictly vegetarian individuals with no known vascular risk factors. One suffered a stroke, and the other had multiple strokes. Why? Most probably because they weren’t taking vitamin B12 supplements, which leads to high homocysteine levels, which can attack our arteries.

    So, those eating plant-based who fail to supplement with B12 may increase their risk of both heart disease and stroke. However, as you can see in the graph below and at 0:47 in my video How to Test for Functional Vitamin B12 Deficiency, vegetarians have so many heart disease risk factor benefits that they are still at lower risk overall, but this may help explain why vegetarians were found to have more stroke. This disparity would presumably disappear with adequate B12 supplementation, and the benefit of lower heart disease risk would grow even larger.

    Compared with non-vegetarians, vegetarians enjoy myriad other advantages, such as better cholesterol, blood pressure, blood sugars, and obesity rates. But, what about that stroke study? Even among studies that have shown benefits, “the effect was not as pronounced as expected, which may be a result of poor vitamin B12 status due to a vegetarian diet. Vitamin B12 deficiency may negate the cardiovascular disease prevention benefits of vegetarian diets. To further reduce the risk of cardiovascular disease, vegetarians should be advised to use vitamin B12 supplements.” 

    How can you determine your B12 status? By the time you’re symptomatic with B12 deficiency, it’s too late. And, initially, the symptoms can be so subtle that you might even miss them. What’s more, you develop metabolic vitamin B12 deficiency well before you develop a clinical deficiency, so there’s “a missed opportunity to prevent dementia and stroke” when you have enough B12 to avoid deficiency symptoms, but not enough to keep your homocysteine in check. “Underdiagnosis of this condition results largely from a failure to understand that a normal serum [blood level] B12 may not reflect an adequate functional B12 status.” The levels of B12 in our blood do not always represent the levels of B12 in our cells. We can have severe functional deficiency of B12 even though our blood levels are normal or even high.

    “Most physicians tend to assume that if the serum B12 is ‘normal,’ there is no problem,” but, within the lower range of normal, 30 percent of patients could have metabolic B12 deficiency, with high homocysteine levels. 

    Directly measuring levels of methylmalonic acid (MMA) or homocysteine is a “more accurate reflection of vitamin B12 functional statuses.” Methylmalonic acid can be checked with a simple urine test; you’re looking for less than a value of 4 micrograms per milligram of creatinine. “Elevated MMA is a specific marker of vitamin B12 deficiency while Hcy [homocysteine] rises in both vitamin B12 and folate deficiencies.” So, “metabolic B12 deficiency is strictly defined by elevation of MMA levels or by elevation of Hcy in folate-replete individuals,” that is, in those getting enough folate. Even without eating beans and greens, which are packed with folate, folic acid is added to the flour supply by law, so, these days, high homocysteine levels may be mostly a B12 problem. Ideally, you’re looking for a homocysteine level in your blood down in the single digits.

    Measured this way, “the prevalence of subclinical functional vitamin B12 deficiency is dramatically higher than previously assumed…” We’re talking about 10 to 40 percent of the general population, more than 40 percent of vegetarians, and the majority of vegans who aren’t scrupulous about getting their B12. Some suggest that those on plant-based diets should check their vitamin B12 status every year, but you shouldn’t need to if you’re adequately supplementing. 

    There are rare cases of vitamin B12 deficiency that can’t be picked up on any test, so it’s better to just make sure you’re getting enough.

    If you do get your homocysteine tested and it’s still too high, up in the double digits despite B12 supplementation and eating beans and greens, I have a suggestion for you in the final videos of this series, which we’ll turn to next with: Should Vegetarians Take Creatine to Normalize Homocysteine? and The Efficacy and Safety of Creatine for High Homocysteine.

    How did we end up here? To watch the full series if you haven’t yet, check the related posts below. 

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    Michael Greger M.D. FACLM

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  • What About Homocysteine, Vitamin B12, and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Homocysteine, Vitamin B12, and Vegetarians’ Stroke Risk?  | NutritionFacts.org

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    Not taking vitamin B12 supplements or regularly eating B12-fortified foods may explain the higher stroke risk found among vegetarians.

    Leonardo da Vinci had a stroke. Might his vegetarian diet have been to blame? “His stroke…may have been related to an increase in homocysteine level because of the long duration of his vegetarian diet.” A suboptimal intake of vitamin B12 is common in those eating plant-based diets (unless they take B12 supplements or regularly eat B12-fortified foods) and can lead to an increased level of homocysteine in the blood, which “is accepted as an important risk factor for stroke.”

    “Accepted” may be overstating it as there is still “a great controversy” surrounding the connection between homocysteine and stroke risk. But, as you can see in the graph below and at 0:57 in my video Vegetarians and Stroke Risk Factors: Vitamin B12 and Homocysteine?, those with higher homocysteine levels do seem to have more atherosclerosis in the carotid arteries that lead up to the brain, compared to those with single-digit homocysteine levels, and they also seem to be at higher risk for clotting ischemic strokes in observational studies and, more recently, bleeding hemorrhagic strokes, as well as increased risk of dying from cardiovascular disease and all causes put together. 

    Even more convincing are the genetic data. About 10 percent of the population has a gene that increases homocysteine levels by about 2 points, and they appear to have significantly higher odds of having a stroke. Most convincing would be randomized, double-blind, placebo-controlled trials to prove that lowering homocysteine with B vitamins can lower strokes, and, indeed, that appears to be the case for clotting strokes: Strokes with homocysteine-lowering interventions were more than five times as likely to reduce stroke compared with placebo.

    Ironically, one of the arguments against the role of homocysteine in strokes is that, “assuming that vegetarians have lower vitamin B12 concentrations than meat-eaters and that low vitamin B12 concentrations cause ischaemic stroke, then the incidence of stroke should be increased among vegetarians…but this is not the case.” However, it has never been studied until now.

    As you can see in the graph below and at 2:16 in my video, the EPIC-Oxford study researchers found that vegetarians do appear to be at higher risk.

    And no wonder, as about a quarter of the vegetarians and nearly three-quarters of the vegans studied were vitamin B12-depleted or B12-deficient, as you can see below and at 2:23, and that resulted in extraordinarily high homocysteine levels.

    Why was there so much B12 deficiency? Because only a small minority were taking a dedicated B12 supplement. And, unlike in the United States, B12 fortification of organic foods isn’t allowed in the United Kingdom. So, while U.S. soymilk and other products may be fortified with B12, UK products may not. We don’t see the same problem among U.S. vegans in the Adventist study, presumably because of the B12 fortification of commonly eaten foods in the United States. It may be no coincidence that the only study I was able to find that showed a significantly lower stroke mortality risk among vegetarians was an Adventist study.

    Start eating strictly plant-based without B12-fortified foods or supplements, and B12 deficiency can develop. However, that was only for those not eating sufficient foods fortified with B12. Those eating plant-based who weren’t careful about getting a regular reliable source of B12 had lower B12 levels and, consequently, higher homocysteine levels, as you can see below and at 3:27 in my video.

    The only way to prove vitamin B12 deficiency is a risk factor for cardiovascular disease in vegetarians is to put it to the test. When researchers measured the amount of atherosclerosis in the carotid arteries, the main arteries supplying the brain, “no significant difference” was found between vegetarians and nonvegetarians. They both looked just as bad even though vegetarians tend to have better risk factors, such as lower cholesterol and blood pressure. The researchers suggest that B12 deficiency plays a role, but how do they know? Some measures of artery function weren’t any better either. Again, they surmised that vitamin B12 deficiency was overwhelming the natural plant-based benefits. “The beneficial effects of vegetarian diets on lipids and blood glucose [cholesterol and blood sugars] need to be advocated, and efforts to correct vitamin B12 deficiency in vegetarian diets can never be overestimated.”

    Sometimes vegetarians did even worse. Worse artery wall thickness and worse artery wall function, “raising concern, for the first time, about the vascular health of vegetarians”—more than a decade before the new stroke study. Yes, their B12 was low, and, yes, their homocysteine was high, “suggest[ing] that vitamin B12 deficiency in vegetarians might have adverse effects on their vascular health.” What we need, though, is an interventional study, where participants are given B12 to see if that fixes it, and here we go. The title of this double-blind, placebo-controlled, randomized crossover study gives it away: “Vitamin B-12 Supplementation Improves Arterial Function in Vegetarians with Subnormal Vitamin B-12 Status.” So, compromised vitamin B12 status among those eating more plant-based diets due to not taking B12 supplements or regularly eating vitamin B12-fortified foods may explain the higher stroke risk found among vegetarians.

    Unfortunately, many vegetarians resist taking vitamin B12 supplements due to “misconceptions,” like “hold[ing] on to the old myth that deficiency of this vitamin is rare and occurs only in a small proportion of vegans.” “A common mistake is to think that the presence of dairy products and eggs in the diet, as in LOV [a lacto-ovo vegetarian diet], can still ensure a proper intake [of B12]…despite excluding animal flesh.”

    Now that we may have nailed the cause, maybe “future studies with vegetarians should focus on identifying ways to convince vegetarians to take vitamin B12 supplements to prevent a deficiency routinely.” 

    I have updated my recommendation for B12 supplementation. I now suggest at least 2,000 mcg (µg) of cyanocobalamin once weekly, ideally as a chewable, sublingual, or liquid supplement taken on an empty stomach, or at least 50 mcg daily of supplemental cyanocobalamin. (You needn’t worry about taking too much.) You can also have servings of B12-fortified foods three times a day (at each meal), each containing at least 190% of the Daily Value listed on the nutrition facts label. (Based on the new labeling mandate that started on January 1, 2020, the target is 4.5 mcg three times a day.) Please note, though, that those older than the age of 65 have only one option: to take 1,000 micrograms a day. 

    We started this series on what to eat and not eat for stroke prevention, and whether vegetarians really have a higher stroke risk. Check related posts for the last few videos that looked at specific factors.

    Stay tuned for: 

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    Michael Greger M.D. FACLM

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  • Unbelievable facts

    Unbelievable facts

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    The sun “gives” people vitamin D by converting cholesterol in the skin into vitamin D3,…

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  • What About Saturated Fat and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Saturated Fat and Vegetarians’ Stroke Risk?  | NutritionFacts.org

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    How can we explain the drop in stroke risk as the Japanese diet became westernized with more meat and dairy?

    As Japan westernized, the country’s stroke rate plummeted, as you can see in the graph below and at 0:15 in my video Vegetarians and Stroke Risk Factors: Saturated Fat?. 

    Stroke had been a leading cause of death in Japan, but the mortality rate decreased sharply as they moved away from their traditional diets and started eating more like those in the West. Did the consumption of all that extra meat and dairy have a protective effect? After all, their intake of animal fat and animal protein was going up at the same time their stroke rates were going down, as shown below and at 0:35 in my video. 

    Commented a noted Loma Linda cardiology professor, “Protection from stroke by eating animal foods? Surely not!…Many vegetarians, like myself, have almost come to expect the data to indicate that they have an advantage, whatever the disease that is being considered. Thus, it is disquieting to find evidence in a quite different direction for at least one subtype of stroke.” 

    Can dietary saturated fat, like that found in meat and dairy, be beneficial in preventing stroke risk? There appeared to be a protective association—but only in East Asian populations, as you can see below and at 1:11 in my video. 

    High dietary saturated fat was found to be associated with a lower risk of stroke in Japanese but not in non-Japanese. So, what was it about the traditional Japanese diet that the westernization of their eating habits made things better when it came to stroke risk? Well, at the same time, their meat and dairy intake was going up, and their salt intake was going down, as you can see below and at 1:40. 

    The traditional Japanese diet was packed with salt. They had some of the highest salt intakes in the world, about a dozen spoonsful of salt a day. Before refrigeration became widely available, they ate all sorts of salted, pickled, and fermented foods from soy sauce to salted fish. In the areas with twice the salt intake, they had twice the stroke mortality, but when the salt intake dropped, so did the stroke death rates, because when the salt consumption went down, their blood pressure went down, too. High blood pressure is perhaps “the single most important potentially modifiable risk factor for stroke,” so it’s no big mystery why the westernization of the Japanese diet led to a drop in stroke risk.  

    When they abandoned their more traditional diets, their obesity rates went up and so did their diabetes and coronary artery disease, but, as they gave up the insanely high salt intake, their insanely high stroke rates correspondingly fell. 

    Stomach cancer is closely associated with excess salt intake. When you look at their stomach cancer rates, they came down beautifully as they westernized their diets away from salt-preserved foods, as you can see in the graph below and at 2:50 in my video. 

    But, of course, as they started eating more animal foods like dairy, their rates of fatal prostate cancer, for example, shot through the roof. Compared to Japan, the United States has 7 times more deaths from prostate cancer, 5 times more deadly breast cancer, 3 times more colon cancer and lymphoma mortality, and 6 to 12 times the death rate from heart disease, as you can see in the graph below and at 3:15 in my video. Yes, Japanese stroke and stomach cancer rates were higher, but they were also eating up to a quarter cup of salt a day. 

    That would seem to be the most likely explanation, rather than some protective role of animal fat. And, indeed, it was eventually acknowledged in the official Japanese guidelines for the prevention of cardiovascular disease: “Refrain from the consumption of large amounts of fatty meat, animal fat, eggs, and processed foods…”

    Now, one of the Harvard cohorts found a protective association between hemorrhagic strokes and both saturated fat and trans fat, prompting a “sigh of relief…heard throughout the cattle-producing Midwestern states,” even though the researchers concluded that, of course, we all have to cut down on animal fat and trans fat for the heart disease benefit. Looking at another major Harvard cohort, however, they found no such protective association for any kind of stroke, and when they put all the studies together, zero protection was found across the board, as you can see below and at 4:07 in my video. 

    Observational studies have found that higher LDL cholesterol seems to be associated with a lower risk of hemorrhagic stroke, raising the possibility that cholesterol may be “a double-edged sword,” by decreasing the risk of ischemic stroke but increasing the risk of hemorrhagic stroke. But low cholesterol levels in the aged “may be a surrogate for nutritional deficiencies…or a sign of debilitating diseases,” or perhaps the individuals were on a combination of cholesterol-lowering drugs and blood thinners, and that’s why we tend to see more brain bleeds in those with low cholesterol. You don’t know until you put it to the test.

    Researchers put together about two dozen randomized controlled trials and found that the lower your cholesterol, the better when it comes to overall stroke risk, with “no significant increase in hemorrhagic stroke risk with lower achieved low-density lipoprotein [LDL] cholesterol levels.”

    The genetic data appear mixed, with some suggesting a lifetime of elevated LDL would give you a higher hemorrhagic stroke risk, while other data suggest more of that double-edged sword effect. However, with lower cholesterol, “any possible excess of hemorrhagic [bleeding] stroke is greatly outweighed by the protective effect against ischaemic stroke,” the much more common clotting type of stroke, not to mention heart disease. It may be on the order of 18 fewer clotting strokes for every 1 extra bleeding stroke with cholesterol-lowering. 

    Does this explain the increased stroke risk found among vegetarians? Hemorrhagic stroke is the type of stroke that appeared higher in vegetarians, but the cholesterol levels in vegans were even lower, and, if anything, vegans trended towards a higher clotting stroke risk, so it doesn’t make sense. If there is some protective factor in animal foods, it is to be hoped that a diet can be found that still protects against the killer number one, heart disease, without increasing the risk of the killer number five, stroke. But, first, we have to figure out what that factor is, and the hunt continues. 

    Aren’t there studies suggesting that saturated fat isn’t as bad as we used to think? Check out: 

    Just like the traditional Japanese diet had a lot going for it despite having high sodium as the fatal flaw, what might be the Achilles’ heel of plant-based diets when it comes to stroke risk? 

    This is the seventh video in this stroke series. See the related posts below for the others.

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    Michael Greger M.D. FACLM

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  • The 411 on Statins | NutritionFacts.org

    The 411 on Statins | NutritionFacts.org

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    The cholesterol-lowering statin drug Lipitor has become the best-selling drug of all time, generating more than $140 billion in global sales. This class of drugs garnered so much enthusiasm in the medical community that some U.S. health authorities facetiously proposed they be added to the public water supply like fluoride is. One cardiology journal even offered the tongue-in-cheek suggestion for fast-food restaurants to offer “MacStatin” [sic] condiments along with ketchup packets to help neutralize the effects of unhealthy dietary choices.

    What Are Statins and How Do They Work?

    Statins are drugs that can lower cholesterol. They work by blocking a substance that our body requires to make cholesterol.

    Are Statins Bad for You?

    Although statins may be effective at lowering cholesterol and potentially helping to reduce the risk of heart disease and even stroke, they come with a host of possible side effects that may do much more harm than good.

    What Possible Side Effects?

    As I discuss in the video Who Should Take Statins?, muscle-related side effects from cholesterol-lowering statin drugs “are often severe enough [to make] patients stop taking [them]. Of course, these side effects could be coincidental or psychosomatic and nothing to do with the drug,” given that many clinical trials show such side effects are rare. Of course, it is also possible that studies funded by the drug companies themselves may under-report side effects. The bottom line is that there’s an urgent need to establish the true incidence of statin side effects.

    Researchers have found that those taking statins are significantly more likely to develop type 2 diabetes than those randomized to placebo sugar pills. Why? We’re still not exactly sure, but statins may have the double-whammy effect of impairing insulin secretion from the pancreas, as well as diminishing insulin’s effectiveness by increasing insulin resistance.

    Even short-term statin use may approximately “double the odds of developing diabetes and diabetic complications,” and increased risks may persist for years after stopping statins.

    Who Should Take Statins?

    How should you decide if a statin is right for you? “If you have a history of heart disease or stroke, taking a statin medication is recommended.” Period. Full stop. No discussion needed. However, if you don’t have any known cardiovascular disease, then the decision should be based on calculating your own personal risk, which you can easily do online if you know your cholesterol and blood pressure numbers, with the American College of Cardiology risk estimator or the Framingham risk profiler. (My favorite is the ACC estimator because it gives your current ten-year risk, as well as your lifetime risk.)

    Under the current guidelines, if your ten-year risk is below 5 percent, unless there are extenuating circumstances, you should stick to diet, exercise, and smoking cessation to bring down your numbers. In contrast, if your ten-year risk hits or exceeds 20 percent, then the recommendation is to add a statin drug on top of making lifestyle modifications. Under 7.5 percent, the tendency is to stick with lifestyle changes unless there are risk-enhancing factors; above 7.5 percent, move towards adding drugs. What are the risk-enhancing factors to take into account when making the decision? A bad family history, really high LDL, metabolic syndrome, chronic kidney or inflammatory conditions, and persistently high triglycerides, C-reactive protein, or LP(a).

    Relative Risk vs. Absolute Risk

    One of the problems with communicating statin evidence to support shared decision-making is that most doctors have a poor understanding of concepts of risk, probability, and statistics, but that understanding is critical for preventive medicine. As discussed in my video Are Doctors Misleading Patients About Statin Risks and Benefits?, when doctors offer a cholesterol-lowering drug, they’re doing something quite different from treating a patient who is sick.

    When drug companies say a statin reduces the risk of a heart attack by 36 percent, that’s the relative risk. In a large clinical study, 3 percent of patients not taking the statin drug had a heart attack within a certain amount of time, compared to 2 percent taking the drug. So, the drug dropped heart attack risk from about 3 percent to 2 percent, which is about a one-third drop—hence, the 36 percent reduced relative risk statistic. Another way to look at the change from 3 percent to 2 percent is that the absolute risk only dropped 1 percent. So, in effect, one’s chance of avoiding a heart attack over the next few years may be about 97 percent without treatment, but it can be increased to about 98 percent by taking daily statin drug. Yet another way to look at it: A hundred people would need to take the drug to prevent a single heart attack.

    The Myth vs. the Reality

    If you ask patients what they were led to believe, they think the chance of avoiding a heart attack within a few years on statins is 1 in 2, when it’s really 1 in a 100. And, if you ask, they want an absolute risk reduction of at least 30 percent or so to take a cholesterol-lowering drug every day, whereas the actual absolute risk reduction is only about 1 percent. So, the dirty little secret is that if patients knew the truth about how little these drugs actually worked, almost no one would agree to take them. So, doctors are either not educating their patients or they’re actively misinforming them.

    Weighing the Risks and Benefits of Statins

    If all those numbers are blurring together, the Mayo Clinic developed a great visualization tool. For individuals at average risk who do not take a daily statin, 10 out of 100 may have a heart attack over the next ten years. However, if all 100 people took a statin every day for those ten years, 8 would have a heart attack and 2 would be spared. That’s about a 1 in 50 chance that taking the drug would help you avert a heart attack over the next decade. What if you have no known heart disease and you take statins for a few years? The chance statins will actually save your life is about 1 in 250.

    What are the downsides? The cost and inconvenience of taking a pill every day, which can cause some gastrointestinal side effects, muscle aching and stiffness in maybe 5 percent, reversible liver inflammation in 2 percent, and more serious damage in perhaps 1 in 20,000 patients.

    Mayo Clinic's visualization tool for the benefits and risks of statins

    If you want a more personalized approach, calculate your ten-year risk. I cover this in more detail in my video The True Benefits vs. Side Effects of Statins.

    Alternatives to Statins?

    As I discuss in my video How Much Longer Do You Live on Statins?, taking statins can enable you to live years longer because, for every millimole per liter you drop your bad LDL cholesterol, you may live three or even six years longer, depending on which study you’re reading. A millimole in U.S. units (mg/dL) is 39 points. Drop your LDL cholesterol about 39 mg/dL or 1 mmol/L, and you could live years longer. Exercise your whole life, and you may only increase your lifespan by six months, whereas stopping smoking may net you nine months. So, how can you drop your LDL cholesterol by about 39 points? You can accomplish that by taking drugs every day, or you can achieve that within just two weeks of eating a diet packed with fruits, vegetables, and nuts.

    table showing the effects of a vegetable diet on cholesterol levels

    A plant-based diet has been shown to substantially reduce cholesterol levels and cardiovascular risk, as well as obesity, hypertension, and systemic inflammation—without negative side effects.

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    Michael Greger M.D. FACLM

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  • The Stroke Risk of Vegetarians  | NutritionFacts.org

    The Stroke Risk of Vegetarians  | NutritionFacts.org

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    The first study in history on the incidence of stroke in vegetarians and vegans suggests they may be at higher risk.

    “When ranked in order of importance, among the interventions available to prevent stroke, the three most important are probably diet, smoking cessation, and blood pressure control.” Most of us these days are doing pretty good about not smoking, but less than half of us exercise enough. And, according to the American Heart Association, only 1 in 1,000 Americans is eating a healthy diet and less than 1 in 10 is even eating a moderately healthy diet, as you can see in the graph below and at 0:41 in my video Do Vegetarians Really Have Higher Stroke Risk?. Why does it matter? It matters because “diet is an important part of stroke prevention. Reducing sodium intake, avoiding egg yolks, limiting the intake of animal flesh (particularly red meat), and increasing the intake of whole grains, fruits, vegetables, and lentils….Like the sugar industry, the meat and egg industries spend hundreds of millions of dollars on propaganda, unfortunately with great success.” 

    The paper goes on to say, “Box 1 provides links to information about the issue.” I was excited to click on the hyperlink for “Box 1” and was so honored to see four links to my videos on egg industry propaganda, as you can see below and at 1:08 in my video. 

    The strongest evidence for stroke protection lies in increasing fruit and vegetable intake, with more uncertainty regarding “the role of whole grains, animal products, and dietary patterns,” such as vegetarian diets. One would expect meat-free diets would do great. Meta-analyses have found that vegetarian diets lower cholesterol and blood pressure, as well as enhance weight loss and blood sugar control, and vegan diets may work even better. All the key biomarkers are going in the right direction. Given this, you may be surprised to learn that there hadn’t been any studies on the incidence of stroke in vegetarians and vegans until now. And if you think that is surprising, wait until you hear the results. 

    “Risks of Ischaemic Heart Disease and Stroke in Meat Eaters, Fish Eaters, and Vegetarians Over 18 Years of Follow-Up: Results from the Prospective EPIC-Oxford Study”: There was less heart disease among vegetarians (by which the researchers meant vegetarians and vegans combined). No surprise. Been there, done that. But there was more stroke, as you can see below, and at 2:14 in my video. 

    An understandable knee-jerk reaction might be: Wait a second, who did this study? Was there a conflict of interest? This is EPIC-Oxford, world-class researchers whose conflicts of interest may be more likely to read: “I am a member of the Vegan Society.”

    What about overadjustment? When the numbers over ten years were crunched, the researchers found 15 strokes for every 1,000 meat eaters, compared to only 9 strokes for every 1,000 vegetarians and vegans, as you can see below and at 2:41 in my video. In that case, how can they say there were more strokes in the vegetarians? This was after adjusting for a variety of factors. The vegetarians were less likely to smoke, for example, so you’d want to cancel that out by adjusting for smoking to effectively compare the stroke risk of nonsmoking vegetarians to nonsmoking meat eaters. If you want to know how a vegetarian diet itself affects stroke rates, you want to cancel out these non-diet-related factors. Sometimes, though, you can overadjust. 

    The sugar industry does this all the time. This is how it works: Imagine you just got a grant from the soda industry to study the effect of soda on the childhood obesity epidemic. What could you possibly do after putting all the studies together to conclude that there was a “near zero” effect of sugary beverage consumption on body weight? Well, since you know that drinking liquid candy can lead to excess calories that can lead to obesity, if you control for calories, if you control for a factor that’s in the causal chain, effectively only comparing soda drinkers who take in the same number of calories as non-soda-drinkers, then you could undermine the soda-to-obesity effect, and that’s exactly what they did. That introduces “over adjustment bias.” Instead of just controlling for some unrelated factor, you control for an intermediate variable on the cause-and-effect pathway between exposure and outcome.

    Overadjustment is how meat and dairy industry-funded researchers have been accused of “obscuring true associations” between saturated fat and cardiovascular disease. We know that saturated fat increases cholesterol, which increases heart disease risk. Therefore, if you control for cholesterol, effectively only comparing saturated fat eaters with the same cholesterol levels as non-saturated-fat eaters, that could undermine the saturated fat-to-heart disease effect.

    Let’s get back to the EPIC-Oxford study. Since vegetarian eating lowers blood pressure and a lowered blood pressure leads to less stroke, controlling for blood pressure would be an overadjustment, effectively only comparing vegetarians to meat eaters with the same low blood pressure. That’s not fair, since lower blood pressure is one of the benefits of vegetarian eating, not some unrelated factor like smoking. So, that would undermine the afforded protection. Did the researchers do that? No. They only adjusted for unrelated factors, like education, socioeconomic class, smoking, exercise, and alcohol. That’s what you want. You want to tease out the effects of a vegetarian diet on stroke risk. You want to try to equalize everything else to tease out the effects of just the dietary choice. And, since the meat eaters in the study were an average of ten years older than the vegetarians, you can see how vegetarians could come out worse after adjusting for that. Since stroke risk can increase exponentially with age, you can see how 9 strokes among 1,000 vegetarians in their 40s could be worse than 15 strokes among 1,000 meat-eaters in their 50s. 

    The fact that vegetarians had greater stroke risk despite their lower blood pressure suggests there’s something about meat-free diets that so increases stroke risk it’s enough to cancel out the blood pressure benefits. But, even if that’s true, you would still want to eat that way. As you can see in the graph below and at 6:16 in my video, stroke is our fifth leading cause of death, whereas heart disease is number one. 

    So, yes, in the study, there were more cases of stroke in vegetarians, but there were fewer cases of heart disease, as you can see below and at 6:29. If there is something increasing stroke risk in vegetarians, it would be nice to know what it is in hopes of figuring out how to get the best of both worlds. This is the question we will turn to next. 

    I called it 21 years ago. There’s an old video of me on YouTube where I air my concerns about stroke risk in vegetarians and vegans. (You can tell it’s from 2003 by my cutting-edge use of advanced whiteboard technology and the fact that I still had hair.) The good news is that I think there’s an easy fix.

    This is the third in a 12-video series on stroke risk. Links to the others are in the related posts below.

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    Michael Greger M.D. FACLM

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  • Eating to Lower Lp(a)  | NutritionFacts.org

    Eating to Lower Lp(a)  | NutritionFacts.org

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    What should we eat—and not eat—to lower the cardiovascular disease risk factor lipoprotein(a)?

    Lipoprotein A, also known as Lp(a), is an independent, genetic, and causal factor for cardiovascular disease and heart attacks. At any level of LDL cholesterol, our risk of heart attack and stroke is two- to three-fold higher when our Lp(a) is elevated. With a high enough Lp(a) level, atherosclerosis continues to progress even if we get our LDL cholesterol way down, which may help explain why so many people continue to have heart attacks and strokes even under treatment for high cholesterol. It’s been suggested that “it would be worthwhile to check Lp(a) levels in a patient who has suffered an event but has no traditional risk factors to explain it.” What’s the point of checking it, though, if there isn’t much we can do about it? “To date, no drug to reduce circulating Lp(a) levels has been approved for clinical use.”

    Some researchers blame our lack of knowledge on the fact that Lp(a) is not found in typical lab animals, like rats and mice. It’s only found in two places in nature: primates and hedgehogs. Hedgehogs? How strange is that? No wonder Lp(a) is “an enigmatic protein that has mystified medical scientists ever since” it was first discovered more than half a century ago. But who needs mice when you have men? The level in our bloodstream is “primarily determined” by genetics. For the longest time, Lp(a) was not thought to be significantly influenced by factors such as diet. Given its similarity to LDL, though, one might assume lifestyle changes, “such as increased physical activity or the adoption of a healthy diet,” would help. “However, the effects of these interventions on Lp(a) concentrations are so far either only marginal or lacking in evidence,” but might that be because they have not tried a plant-based diet yet?

    As I discuss in my video How to Lower Lp(a) with Diet, when it comes to raising LDL cholesterol, we’ve known for years that the trans fats found in meat and dairy are just as bad as the industrially produced trans fats found in partially hydrogenated oil and junk food. But, when it comes to Lp(a), as you can see below and at 2:05 in my video, trans fats from meat and dairy appear to be even worse. 

    Just cutting out meat and following a lacto-ovo vegetarian diet did not appear to help, but, as you can see below and at 2:19 in my video, when study participants were put on a whole food, plant-based diet packed with a dozen servings of fruits and vegetables a day, their Lp(a) levels dropped by 16 percent within four weeks. 

    Of course, in those 30 days, the study subjects also lost about 15 pounds, as you can see below and at 2:28, but weight loss does not appear to affect Lp(a) levels, so you figure that it must have been due to the diet. 

    If you’re already eating a healthy plant-based diet and your Lp(a) levels are still too high, are there any particular foods that can help? As with cholesterol, even if the average total cholesterol of those eating strictly plant-based may be right on target at less than 150, with an LDL under 70, there’s a bell curve with plus or minus 30 points that fall on either side, as you can see below and at 2:45 in my video. 

    Enter the “Portfolio Diet,” which is not only plant-based, but also adds specific cholesterol-lowing foods—so, think nuts, beans, oatmeal, and berries to drag cholesterol down even further. The infographic is below and at 3:11 in my video.  

    What about Lp(a)? Nuts have been put to the test. Two and a half ounces of almonds every day dropped levels, but only by about 8 percent. That is better than another nut study, though, that found no effect at all, as you can see below and at 3:29 in my video. An additional study found “no significant changes,” and researchers reported that subjects in their study “did not experience a change in Lp(a).” Ah, nuts.  

    There is one plant that appears to drop Lp(a) levels by 20 percent, which is enough to take people exceeding the U.S. cut-off down to a more optimum level. And that plant is a fruit: Emblica officinalis, otherwise known as amla or Indian gooseberry. A randomized, double-blind, placebo-controlled study asked smokers before and after the trial about their “mouth hygiene, cough with expectoration, shortness of breath on exertion, loss of appetite, feelings of impending doom, palpitation, sleep deprivation, irritability, heartburn and tiredness,” as well as such objective measurements as their blood count, cholesterol, DNA damage, antioxidant status, and lung function. The amla extract used “showed a significant improvement compared to the placebo group in all the subjective and objective parameters tested with no reports of adverse events.” No side effects at all. That’s unbelievable! No, that’s unbelievable. And indeed, it’s completely not true.  

    Yes, subjective complaints got better in the amla group, but they got better in the placebo group, too, with arbitrary scoring systems and no statistical analysis whatsoever. And, of the two dozen objective measures, only half could be said to reach any kind of before-and-after statistical significance and only three were significant enough to account for the fact that if you measure two dozen things, a few might pop up as positive if only by chance. Any time you see this kind of spin in the abstract, which is sometimes the only part of a study people read, you should suspect some kind of conflict of interest. However, no conflicts of interest were declared by the researchers, but that’s bullsh*t, as the study was funded by the very company selling those amla supplements! Sigh.

    Anyway, one of those three significant findings was the Lp(a), so it might be worth a try in the context of a plant-based diet, which, in addition to helping with weight loss, can dramatically improve blood pressure (even after cutting down on blood pressure medications) and contribute to a 25-point drop in LDL cholesterol. Also, it may contribute to a 30 percent drop in C-reactive protein and significant reductions in other inflammatory markers for “a systemic, cardio-protective effect”—all thanks to this single dietary approach.

    You may be interested in my video on Trans Fat in Meat and Dairy. Did you know that animal products are exempted from the ban? See Banning Trans Fat in Processed Foods but Not Animal Fat.

    For more on amla and what else it can do, check out the related posts below.

    If you missed my previous video on Lp(a), watch Treating High Lp(a)—A Risk Factor for Atherosclerosis. 

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    Michael Greger M.D. FACLM

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  • How to Treat High Lp(a), an Atherosclerosis Risk Factor  | NutritionFacts.org

    How to Treat High Lp(a), an Atherosclerosis Risk Factor  | NutritionFacts.org

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    What could help explain severe coronary disease in someone with a healthy lifestyle who is considered to be at low cardiovascular disease risk? A young man ended up in the ER after a heart attack and was ultimately found to have severe coronary artery disease. Given his age, blood pressure, and cholesterol, his ten-year risk of a heart attack should have only been about 2 percent, but he had a high lipoprotein(a), also known as Lp(a). In fact, it was markedly high at 80 mg/dL, which may help explain it. You can see the same in women: a 27-year-old with a heart attack with a high Lp(a). What is Lp(a), and what can we do about it? 

    As I discuss in my video Treating High Lp(a): A Risk Factor for Atherosclerosis, Lp(a) is an “underestimated cardiovascular risk factor.” It causes coronary artery disease, heart attacks, strokes, peripheral arterial disease, calcified aortic valve disease, and heart failure. And these can occur in people who don’t even have high cholesterol—because Lp(a) is cholesterol, as you can see below and at 1:15 in my video. It’s an LDL cholesterol molecule linked to another protein, which, like LDL, transfers cholesterol into the lining of our arteries, contributing to the inflammation in atherosclerotic plaques. But “this increased risk caused by Lp(a) has not yet gained recognition by practicing physicians.” 

    “The main reason for the limited clinical use of Lp(a) is the lack of effective and specific therapies to lower Lp(a) plasma levels.” Because “Lp(a) concentrations are approximately 90% genetically determined,” the conventional thinking has been you’re just kind of born with higher or lower levels and there isn’t much you can do about it. Even if that were the case, though, you might still want to know about it. If it were high, for instance, that would be all the more reason to make sure all the other risk factors that you do have more control over are as good as possible. It may help you quit smoking, for example, and motivate you to do everything you can to lower your LDL cholesterol as much as possible.  

    Lp(a) levels in the blood can vary a thousand-fold between individuals, “from less than 0.1 mg/dL to as high as 387 mg/dL.” You can see a graph of the odds of heart disease at different levels in the graph below and at 2:20 in my video. Less than 20 mg/dL is probably optimal, with greater than 30 to 50 mg/dL considered to be elevated. Even when the more conservative threshold of greater than 50 mg/dL is used, that describes about 10 to 30 percent of the global population, an estimated 1.4 billion people. So, if we’re in the one in five people with elevated levels, what can we do about it? 

    The way we know that Lp(a) causes atherosclerosis is that we can put it to the ultimate test. There is something called apheresis, which is essentially like a dialysis machine where they can take out your blood, wash out some of the Lp(a), and give your blood back to you. And when you do that, you can reverse the progression of the disease. As you can see in the graph below and at 3:06 in my video, atherosclerosis continues to get worse in the control group, but it gets better in the apheresis group. This is great for proving the role of Lp(a), but it has limited clinical application, given the “cost, limited access to centers, and the time commitment required for biweekly sessions of 2 to 4 h each.” 

    It causes a big drop in blood levels, but they quickly creep back up, so you have to keep going in, as you can see in the graph below and at 3:26 in my video, costing more than $50,000 a year. 

    There has to be a better way. We’ll explore the role diet can play, next.  

    I’ve been wanting to do videos about Lp(a), but there just wasn’t much we could do about it until now. So, how do we lower Lp(a) with diet? Stay tuned for the exciting conclusion in my next video.

    What can we do to minimize heart disease risk? My video How Not to Die from Heart Disease is a good starting point. 

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    Michael Greger M.D. FACLM

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  • Eat Quinoa and Lower Triglycerides? | NutritionFacts.org

    Eat Quinoa and Lower Triglycerides? | NutritionFacts.org

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    How do the nutrition and health effects of quinoa compare to other whole grains?

    “Approximately 90% of the world’s calories are provided by less than one percent of the known 250,000 edible plant species.” The big three are wheat, corn, and rice, and our reliance on them may be unsustainable, given the ongoing climate crisis. This has spurred new interest in “underutilized crops,” like quinoa, which might do better with drought and heat.

    Quinoa has only recently been introduced into the Northern Hemisphere, but humans have been eating quinoa for more than 7,000 years. Is there any truth to its “superfood” designation, or is it all just marketing hooey?

    Quinoa is a “pseudograin,” since the plant it comes from isn’t a type of grass. “Botanically speaking quinoa is an achene, a seed-like fruit with a hard coat,” and it has a lot of vitamins and minerals, but so do all whole grains. It also has a lot of protein. As you can see below and in a series of graphs starting at 1:05 in my video Benefits of Quinoa for Lowering Triglycerides, quinoa has more protein than other grains, but since when do we need more protein? Fiber is what we’re sorely lacking, and its fiber content is relatively modest, compared to barley or rye. Quinoa is pretty strong on folate and vitamin E, though, and it leads the pack on magnesium, iron, and zinc. So, it is nutritious, but when I think superfood, I think of something with some sort of special clinical benefit. Broccoli is a superfood, strawberries are a superfood, and so is garlic, but quinoa? Consumer demand is up, thanks in part to “perceived health benefits,” and it has all sorts of purported benefits in lab animals, but there have been very few human studies. 

    The first trial was a before-and-after study of quinoa granola bars that showed drops in triglycerides and cholesterol, as you can see below and at 1:53 in my video, but it didn’t have a control group, so we don’t know how much of that would have happened without the quinoa. The kind of study I want to see is a randomized controlled trial. When researchers gave participants about a cup of cooked quinoa every day for 12 weeks, they experienced a 36 percent drop in their triglycerides. That’s comparable to what one gets with triglyceride-lowering drugs or high-dose fish oil supplements.

    Which is better, regular quinoa or red quinoa? As you can see in the graph below and at 2:22 in my video, the red variety has about twice the antioxidant power, leading the investigators to conclude that red quinoa “might…contribute significantly to the management and/or prevention of degenerative diseases associated with free radical damage,” but it’s never been put to the test. 

    What about black quinoa? Both red and black quinoa appear to be equally antioxidant-rich, both beating out the more conventional white variety, as you can see in the graph below and at 2:46 in my video. 

    The only caveat I could find is to inform your doctor before your next colonoscopy or else they might mistake quinoa for parasites. As reported in a paper, a “colonoscopy revealed numerous egg-like tan-yellow ovoid objects, 2 to 3 mm in diameter, of unclear cause,” but they were just undigested quinoa.

    For more on the superfoods I mentioned, check the related posts below.

    Isn’t fish oil important to heart health? Find out in my video Is Fish Oil Just Snake Oil?.

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    Michael Greger M.D. FACLM

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  • Do Taxpayer Subsidies Play a Role in the Obesity Epidemic?  | NutritionFacts.org

    Do Taxpayer Subsidies Play a Role in the Obesity Epidemic?  | NutritionFacts.org

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    Why are U.S. taxpayers giving billions of dollars to support the likes of the sugar and meat industries?

    The rise in calorie surplus sufficient to explain the obesity epidemic was less a change in food quantity than in food quality. Access to cheap, high-calorie, low-quality convenience foods exploded, and the federal government very much played a role in making this happen. U.S. taxpayers give billions of dollars in subsidies to prop up the likes of the sugar industry, the corn industry and its high-fructose syrup, and the production of soybeans, about half of which is processed into vegetable oil and the other half is used as cheap feed to help make dollar-menu meat. You can see a table of subsidy recipients below and at 0:49 in my video The Role of Taxpayer Subsidies in the Obesity Epidemic. Why do taxpayers give nearly a quarter of a billion dollars a year to the sorghum industry? When was the last time you sat down to some sorghum? It’s almost all fed to cattle and other livestock. “We have created a food price structure that favors relatively animal source foods, sweets, and fats”—animal products, sugars, and oils.

    The Farm Bill started out as an emergency measure during the Great Depression of the 1930s to protect small farmers but was weaponized by Big Ag into a cash cow with pork barrel politics—including said producers of beef and pork. From 1970 to 1994, global beef prices dropped by more than 60 percent. And, if it weren’t for taxpayers “sweetening the pot” with billions of dollars a year, high-fructose corn syrup would cost the soda industry about 12 percent more. Then we hand Big Soda billions more through the Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamps Program, to give sugary drinks to low-income individuals. Why is chicken so cheap? After one Farm Bill, corn and soy were subsidized below the cost of production for cheap animal fodder. We effectively handed the poultry and pork industries about $10 billion each. That’s not chicken feed—or rather, it is! 

    This is changing what we eat. 

    As you can see below and at 2:03 in my video, thanks in part to subsidies, dairy, meats, sweets, eggs, oils, and soda were all getting relatively cheaper compared to the overall consumer food price index as the obesity epidemic took off, whereas the relative cost of fresh fruits and vegetables doubled. This may help explain why, during about the same period, the percentage of Americans getting five servings of fruits and vegetables a day dropped from 42 percent to 26 percent. Why not just subsidize produce instead? Because that’s not where the money is. 

    “To understand what is shaping our foodscape today, it is important to understand the significance of differential profit.” Whole foods or minimally processed foods, such as canned beans or tomato paste, are what the food business refers to as “commodities.” They have such slim profit margins that “some are typically sold at or below cost, as ‘loss leaders,’ to attract customers to the store” in the hopes that they’ll also buy the “value-added” products. Some of the most profitable products for producers and vendors alike are the ultra-processed, fatty, sugary, and salty concoctions of artificially flavored, artificially colored, and artificially cheap ingredients—thanks to taxpayer subsidies. 

    Different foods reap different returns. Measured in “profit per square foot of selling space” in the supermarket, confectionaries like candy bars consistently rank among the most lucrative. The markups are the only healthy thing about them. Fried snacks like potato chips and corn chips are also highly profitable. PepsiCo’s subsidiary Frito-Lay brags that while its products represented only about 1 percent of total supermarket sales, they may account for more than 10 percent of operating profits for supermarkets and 40 percent of profit growth. 

    It’s no surprise, then, that the entire system is geared towards garbage. The rise in the calorie supply wasn’t just more food but a different kind of food. There’s a dumb dichotomy about the drivers of the obesity epidemic: Is it the sugar or the fat? They’re both highly subsidized, and they both took off. As you can see below and at 4:29 and 4:35 in my video, along with a significant rise in refined grain products that is difficult to quantify, the rise in obesity was accompanied by about a 20 percent increase in per capita pounds of added sugars and a 38 percent increase in added fats. 

     

    More than half of all calories consumed by most adults in the United States were found to originate from these subsidized foods, and they appear to be worse off for it. Those eating the most had significantly higher levels of chronic disease risk factors, including elevated cholesterol, inflammation, and body weight. 

    If it really were a government of, by, and for the people, we’d be subsidizing healthy foods, if anything, to make fruits and vegetables cheap or even free. Instead, our tax dollars are shoveled to the likes of the sugar industry or to livestock feed to make cheap, fast-food meat. 

    Speaking of sorghum, I had never had it before and it’s delicious! In fact, I wish I had discovered it before How Not to Diet was published. I now add sorghum and finger millet to my BROL bowl which used to just include purple barley groats, rye groats, oat groats, and black lentils, so the acronym has become an unpronounceable BROLMS. Anyway, sorghum is a great rice substitute for those who saw my rice and arsenic video series and were as convinced as I am that we need to diversify our grains. 

    We now turn to marketing. After all of the taxpayer-subsidized glut of calories in the market, the food industry had to find a way to get it into people’s mouths. So, next: The Role of Marketing in the Obesity Epidemic. 

    We’re about halfway through this series on the obesity epidemic. If you missed any so far, check out the related videos below.

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    Michael Greger M.D. FACLM

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  • How Much Added Sugar Is Okay?  | NutritionFacts.org

    How Much Added Sugar Is Okay?  | NutritionFacts.org

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    Public health authorities continue to lower the upper tolerable limit of daily added sugar intake.

    Dating back to the original “Dietary Goals for the United States” in 1977, also known as the so-called McGovern Report, leading nutrition scientists didn’t only call for a reduction in meat and other sources of saturated fat and cholesterol, such as dairy and eggs, but also sugar. The goal was to reduce America’s sugar intake to no more than 10 percent of our daily diet.

    “The conclusions would hang sugar,” reported the president of the Sugar Association. “The McGovern Report has to be neutralized.” The National Cattlemen’s Association was on its side and, just like Big Sugar, appealed to the Senate Select Committee to withdraw the report.

    “The Sugar Industry Empire Strikes Back”—and it appeared to work. When the official U.S. Dietary Guidelines were released in 1980 and again in 1985, it was without a specific limit, like 10 percent. It “said, simply, and in just four words, ‘Avoid too much sugar.’” (Whatever that means.) “In 1990, it went to five words, ‘Use sugars only in moderation,’ and in 1995 to six: ‘Choose a diet moderate in sugars.’” In 2000, it at least went back to limiting intake—specifically, “‘Choose beverages and foods to limit your intake of sugars’ (ten words), but even that was too strong. Under pressure from sugar lobbyists, the government agencies substituted the word ‘moderate’ for ‘limit’ so it read ‘Choose beverages and foods to moderate your intake of sugars.’” Then, the 2005 guidelines committee dropped the s-word completely, encouraging Americans to “Choose carbohydrates wisely…” Again, what does that mean? If only there were a dietary guidelines committee that could guide us….

    The Sugar Association expressed optimism about that 2005 Committee. In its Sugar E-News, it wrote that Sugar Association Incorporated (SAI) “is committed to the protection and promotion of sucrose [table sugar] consumption. Any disparagement of sugar will be met with forceful, strategic public comments”—and it wasn’t kidding. “In 2003, [the World Health Organization] WHO released a joint report with the Food and Agriculture Organization entitled Diet, nutrition and the prevention of chronic diseases which, for the first time [since the McGovern Report], called for a reduction in sugar intake to under 10% of total dietary energy [caloric] consumption.” The Sugar Association responded by threatening to get the United States to withdraw all funding from the WHO. You can see it yourself in black and white at 2:22 in my video Friday Favorites: The Recommended Daily Added Sugar Intake. The Sugar Association threatened to pressure Congress to withdraw funding from the World Health Organization—polio vaccinations and AIDS medications be damned! Don’t mess with the candy man. The threat was described as “tantamount to blackmail and worse than any pressure exerted by the tobacco lobby.” 

    Fifteen years later and 40 years after the first proposed McGovern Report, the 2015 to 2020 Dietary Guidelines for Americans lays out the 10 percent limit as a key recommendation: “Consume less than 10 percent of calories per day from added sugars.” This is currently exceeded by every age bracket in the United States starting at age one, as you can see in the graph below and at 2:58 in my video, with adolescents averaging 87 grams of sugar a day. That means the average teen is effectively eating 29 sugar packets a day. 

    The Sugar Association describes the 10 percent limit as “extremely low.” Well, I mean, it is only up to about a dozen spoonsful a day. Of course, there is no dietary requirement for added sugar at all, and every single calorie we get from added sugar is a wasted opportunity to get calories from sources that provide nutrition. To the American Heart Association’s credit, it went further by trying to push added sugar intake down to about 6 percent of calories, for which a single can of soda could send you over the limit. That’s an added sugar limit exceeded by 90 percent of Americans.

    In 2017, the American Heart Association (AHA) released its guidelines for children, recommending they get no more than about six teaspoons per day. In that case, a single serving of nearly a hundred cereals on the U.S. market would exceed the entire recommended daily limit. The AHA recommends no added sugars at all for children under the age of two, a recommendation that’s violated in up to 80 percent of toddlers, as you can see below and at 4:20 in my video. 

    In the United States, “at least 65 countries have implemented dietary guidelines or public health policies to curb sugar consumption to encourage maintenance of healthy body weight.” In the United Kingdom, the Scientific Advisory Committee on Nutrition made new recommendations to reduce added sugars down to 5 percent, which is also the direction the World Health Organization is headed. The WHO always seems to be ahead of the curve. Why? Because its policy-making process is at least partially protected “against industry influence.” Unlike governments, which may have competing interests in commerce and trade, “WHO is exclusively concerned with health.”

    I spoke at a hearing of the 2020 Dietary Guidelines Committee. Watch the highlights and my speech here: Highlights from the 2020 Dietary Guidelines Hearing.

    The sugar industry keeps pretty busy, as you’ll see from my recent videos, Friday Favorites: Are Fortified Kids’ Breakfast Cereals Healthy or Just Candy? and Flashback Friday: Sugar Industry Attempts to Manipulate the Science.

    Check the related posts below for my other popular videos and blogs on sugar.

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    Michael Greger M.D. FACLM

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  • Irregular Meals, Night Shifts, and Metabolic Harms  | NutritionFacts.org

    Irregular Meals, Night Shifts, and Metabolic Harms  | NutritionFacts.org

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    What can shift workers do to moderate the adverse effects of circadian rhythm disruption?

    Shift workers may have higher rates of death from heart disease, stroke, diabetes, dementia, and cardiovascular disease, as well as higher rates of death from cancer. Graveyard shift, indeed! But, is it just because they’re eating out of vending machines or not getting enough sleep? Highly controlled studies have recently attempted to tease out these other factors by putting people on the same diets with the same sleep—but at the wrong time of day. Redistributing eating to the nighttime resulted in elevated cholesterol and increases in blood pressure and inflammation. No wonder shift workers are at higher risk. Shifting meals to the night in a simulated night-shift protocol effectively turned about one-third of the subjects prediabetic in just ten days. Our bodies just weren’t designed to handle food at night, as I discuss in my video The Metabolic Harms of Night Shifts and Irregular Meals.

    Just as avoiding bright light at night can prevent circadian misalignment, so can avoiding night eating. We may have no control over the lighting at our workplace, but we can try to minimize overnight food intake, which has been shown to help limit the negative metabolic consequences of shift work. When we finally do get home in the morning, though, we may disproportionately crave unhealthy foods. In one experiment, 81 percent of participants in a night-shift scenario chose high-fat foods, such as croissants, out of a breakfast buffet, compared to just 43 percent of the same subjects during a control period on a normal schedule.

    Shiftwork may also leave people too fatigued to exercise. But, even at the same physical activity levels, chronodisruption can affect energy expenditure. Researchers found that we burn 12 to 16 percent fewer calories while sleeping during the daytime compared to nighttime. Just a single improperly-timed snack can affect how much fat we burn every day. Study subjects eating a specified snack at 10:00 am burned about 6 more grams of fat from their body than on the days they ate the same snack at 11:00 pm. That’s only about a pat and a half of butter’s worth of fat, but it was the identical snack, just given at a different time. The late snack group also suffered about a 9 percent bump in their LDL cholesterol within just two weeks.

    Even just sleeping in on the weekends may mess up our metabolism. “Social jetlag is a measure of the discrepancy in sleep timing between our work days and free days.” From a circadian rhythm standpoint, if we go to bed late and sleep in on the weekends, it’s as if we flew a few time zones west on Friday evening, then flew back Monday morning. Travel-induced jet lag goes away in a few days, but what might the consequences be of constantly shifting our sleep schedule every week over our entire working career? Interventional studies have yet put it to the test, but population studies suggest that those who have at least an hour of social jet lag a week (which may describe more than two-thirds of people) have twice the odds of being overweight. 

    If sleep regularity is important, what about meal regularity? “The importance of eating regularly was highlighted early by Hippocrates (460–377 BC) and later by Florence Nightingale,” but it wasn’t put to the test until the 21st century. A few population studies had suggested that those eating meals irregularly were at a metabolic disadvantage, but the first interventional studies weren’t published until 2004. Subjects were randomized to eat their regular diets divided into six regular eating occasions a day or three to nine daily occasions in an irregular manner. Researchers found that an irregular eating pattern can cause a drop in insulin sensitivity and a rise in cholesterol levels, as well as reduce the calorie burn immediately after meals in both lean and obese individuals. The study participants ended up eating more, though, on the irregular meals, so it’s difficult to disentangle the circadian effects. The fact that overweight individuals may overeat on an irregular pattern may be telling in and of itself, but it would be nice to see such a study repeated using identical diets to see if irregularity itself has metabolic effects.

    Just such a study was published in 2016: During two periods, people were randomized to eat identical foods in a regular or irregular meal pattern. As you can see in the graph below and at 4:47 in my video, during the irregular period, people had impaired glucose tolerance, meaning higher blood sugar responses to the same food.

    They also had lower diet-induced thermogenesis, meaning the burning of fewer calories to process each meal, as seen in the graph below and at 4:55 in my video.

    The difference in thermogenesis only came out to be about ten calories per meal, though, and there was no difference in weight changes over the two-week periods. However, diet-induced thermogenesis can act as “a satiety signal.” The extra work put into processing a meal can help slake one’s appetite. And, indeed, “lower hunger and higher fullness ratings” during the regular meal period could potentially translate into better weight control over the long term. 

    The series on chronobiology is winding down with just two videos left in this series: Shedding Light on Shedding Weight and Friday Favorites: Why People Gain Weight in the Fall.

    If you missed any of the other videos, see the related posts below. 
     

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    Michael Greger M.D. FACLM

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  • How Healthy Are Ancient Grains?  | NutritionFacts.org

    How Healthy Are Ancient Grains?  | NutritionFacts.org

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    Ancient types of wheat, like kamut, are put to the test for inflammation, blood sugar, and cholesterol control. 

    The number one killer in the United States and around the world is what we eat. As you can see in the graph below and at 0:15 in my video Friday Favorites: Are Ancient Grains Healthier?, our diet kills millions more than tobacco. What are the five most important things we can do to improve our diets, based on the single most comprehensive global study of the health impact of nutrition? Eat less salt, eat more nuts, eat more non-starchy vegetables, eat more fruit, and, finally, eat more whole grains. 
    Any particular type of whole grains? What about so-called ancient grains? Are they any better than modern varieties? For instance, what about kamut, described as “mummy wheat” and supposedly unearthed from an Egyptian tomb?

    After WWII, the wheat industry selected particularly high-yielding varieties for pasta and bread. Over the past few years, though, some of the more ancient grains—“defined as those species that have remained unchanged over the last hundred years” despite agricultural revolutions—have been reintroduced to the market.

    As you can see below and at 1:13 in my video, nutritionally, kamut and einkorn wheat, which is the oldest wheat, have more eyesight-improving yellow carotenoid pigments, such as lutein and zeaxanthin, compared to modern bread and pastry wheat, because the pigments have been bred out of the bread intentionally. People want their white bread white, but modern pasta flour (durum wheat) maintains much of that yellow nutritional hue. 

    As you can see in the graph below and at 1:41 in my video, modern wheat may have less lutein, but it tends to have more vitamin E, as seen in the graph below and at 1:45. Based on straight vitamin and mineral concentrations, it’s pretty much a wash. Both modern and primitive kinds of wheat have a lot of each, but primitive wheats do have more antioxidant capacity, likely due to their greater polyphenol content, as you can see in the graph below and at 2:00 in my video. To know if that makes any difference, though, we have to put it to the test. 

    If you expose human liver cells to digested bread made out of ancient grains (kamut and spelt), heritage kinds of wheat, or modern strains, then expose the cells to an inflammatory stimulus, the modern wheat strains seem less able to suppress the inflammation, as you can see in the graphs below and at 2:09 in my video. The investigators conclude that even though these different grains seem to be very similar nutritionally, they appear to exert different effects on human cells, “confirming the potential health benefits of ancient grains.” 
    That was in a petri dish, though. What about people? If ancient kinds of wheat are better at suppressing inflammation, what if you took people with irritable bowel syndrome (IBS) and randomized them to receive six weeks of wheat products made out of modern wheat or ancient wheat—in this case, kamut? Same amount of wheat, just different types. If there is no difference between the wheats, there’d be no difference in people’s symptoms, right? But, when study participants in the control group were switched to the ancient wheat kamut, they experienced less abdominal pain, less frequent pain, less bloating, more satisfaction with stool consistency, and less interference with their quality of life, compared to the modern wheat. So, after switching to the ancient wheat, they had “a significant global improvement in the extent and severity of symptoms related to IBS…”

    What about liver inflammation? The liver function of those with nonalcoholic fatty liver disease randomized to eat kamut improved, compared to those eating the same amount of regular wheat, suggesting kamut is superior, as you can see below and at 3:47 in my video.

    People with diabetes, had better cholesterol and better insulin sensitivity on the same ancient grain, as shown below and at 3:57.

    And those with heart disease? They had better blood sugar control and better cholesterol, as shown below and at 4:03. 

    And, people without overt heart disease had better artery function, as you can see below and at 4:06 in my video.

    The bottom line is that findings derived from human studies suggest that ancient wheat products are more anti-inflammatory and may improve things like blood sugar control and cholesterol. “Given that the overall number of human interventional trials conducted to date are numerically insufficient, it is not possible to definitively conclude that ancient wheat varieties are superior to all commercial, modern wheat counterparts in reducing chronic disease risk.” However, the best available data do suggest they’re better for us.  

    Regardless of what type of wheat you may eat, a word to the wise: Don’t eat the plastic bread-bag clip. A 45-year-old man presented with bloody stools, and his CT scan showed the offending piece of plastic from his bag of bread, as you can see below and at 4:53 in my video. When the patient was questioned, he “admitted to habitually eating quickly without chewing properly.” 

    Whole grains—ideally intact ones and ancient and modern varieties alike—are an integral part of my Daily Dozen checklist, the healthiest of healthy things I encourage everyone to try to fit into their daily routines.  

    Whole grains are especially good for our microbiome. Learn more in the related posts below.  What about gluten? Also, see the related posts below. 

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    Michael Greger M.D. FACLM

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  • Syncing Your Brain and Body Clocks  | NutritionFacts.org

    Syncing Your Brain and Body Clocks  | NutritionFacts.org

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    Exposure to bright light synchronizes the central circadian clock in our brain, whereas proper meal timing helps sync the timing of different clock genes throughout the rest of our body. 
     
    One of the most important breakthroughs in recent years has been the discovery of “peripheral clocks.” We’ve known for decades about the central clock—the so-called suprachiasmatic nucleus. It sits in the middle of our brain right above the place where our optic nerves cross, allowing it to respond to day and night. Now we also know there are semi-autonomous clocks in nearly every organ of our body. Our heart runs on a clock, our lungs run on one, and so do our kidneys, for instance. In fact, up to 80 percent of the genes in our liver are expressed in a circadian rhythm.

    Our entire digestive tract is, too. The rate at which our stomach empties, the secretion of digestive enzymes, and the expression of transporters in our intestinal lining for absorbing sugar and fat all cycle around the clock. So, too, does the ability of our body fat to sop up extra calories. The way we know these cycles are driven by local clocks, rather than being controlled by our brain, is that you can take surgical biopsies of fat, put them in a petri dish, and watch them continue to rhythm away.

    All of this clock talk is not just biological curiosity. Our health may depend on keeping all of them in sync. “Imagine a child playing on a swing.” Picture yourself pushing, but you become distracted by what’s going on around you in the playground and stop paying attention to the timing of the push. So, you forget to push or you push too early or too late. What happens? Out of sync, the swinging becomes erratic, slows, or even stops. That is what happens when we travel across multiple time zones or have to work the night shift.

    The “pusher” in this case is the light cues falling onto our eyes. Our circadian rhythm is meant to get a “push” from bright light every morning at dawn, but if the sun rises at a different time or we’re exposed to bright light in the middle of the night, this can push our cycle out of sync and leave us feeling out of sorts. That’s an example of a mismatch between the external environment and our central clock. Problems can also arise from a misalignment between the central clock in our brain and all the other organ clocks throughout our body. An extreme illustration of this is a remarkable set of experiments suggesting that even our poop can get jet lag.

    As you can see below and at 2:31 in my video How to Sync Your Central Circadian Clock to Your Peripheral Clocks, our microbiome seems to have its own circadian rhythm.

    Even though the bacteria are down where the sun doesn’t shine, there’s a daily oscillation in both bacterial abundance and activity in our colon, as you can see in the graph below and at 2:43 in my video. Interesting, but who cares? We all should. 

    Check this out: If you put people on a plane and fly them halfway around the world, then feed their poop to mice, those mice grow fatter than mice fed preflight feces. The researchers suggest the fattening flora was a consequence of “circadian misalignment.” Indeed, several lines of evidence now implicate “chronodisruption”—the state in which our central and peripheral clocks diverge out of sync—as playing a role in conditions such as premature aging and cancer, as well as ranging to others like mood disorders and obesity.

    Exposure to bright light is the synchronizing swing pusher for our central clock. What drives our internal organ clocks that aren’t exposed to daylight? Food intake. That’s why the timing of our meals may be so important. Researchers removed all external timing cues by keeping study participants under constant dim light and found that you could effectively decouple central rhythms from peripheral ones just by shifting meal times. They took blood draws every hour and biopsies of the subjects’ fat every six hours to demonstrate the resulting metabolic disarray.

    Just as morning light can help sync the central clock in our brain, morning meals can help sync our peripheral clocks throughout the rest of our body. Skipping breakfast disrupts the normal expression and rhythm of these clock genes themselves, which coincides with adverse metabolic effects. Thankfully, they can be reversed. Take a group of habitual breakfast-skippers and have them eat three meals at 8:00 am, 1:00 pm, and 6:00 pm, and their cholesterol and triglycerides improve, compared to taking meals five hours later at 1:00 pm, 6:00 pm, and 11:00 pm. There is a circadian rhythm to cholesterol synthesis in the body, too, which is also “strongly influenced by food intake.” This is evidenced by the 95 percent drop in cholesterol production in response to a single day of fasting. That’s why a shift in meal timing of just a few hours can result in a 20-point drop in LDL cholesterol, thanks to eating earlier meals, as you can see below and at 5:00 in my video. 

    If light exposure and meal timing help keep everything synced, what happens when our circumstances prevent us from sticking to a normal daytime cycle? We’ll find out in The Metabolic Harms of Night Shifts and Irregular Meals. If you’re just coming into the series, be sure to check out the related posts below.  

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    Michael Greger M.D. FACLM

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  • Circadian Rhythms and Our Blood Sugar Levels  | NutritionFacts.org

    Circadian Rhythms and Our Blood Sugar Levels  | NutritionFacts.org

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    The same meal eaten at the wrong time of day can double blood sugar. 

    We’ve known for more than half a century that our glucose tolerance—the ability of our body to keep our blood sugars under control—declines as the day goes on. As you can see in the graph below and at 0:25 in my video How Circadian Rhythms Affect Blood Sugar Levels, if you hook yourself up to an IV and drip sugar water into your vein at a steady pace throughout the day, your blood sugars will start to go up at about 8:00 pm, even though you haven’t eaten anything and the infusion rate didn’t change.

    The same amount of sugar is going into your system every minute, but your ability to handle it deteriorates in the evening before bouncing right back in the morning. A meal eaten at 8:00 pm can cause twice the blood sugar response as an identical meal eaten at 8:00 am, as shown in the graph below and at 0:51 in my video. It’s as if you ate twice as much. Your body just isn’t expecting you to be eating when it’s dark outside. Our species may have only discovered how to use fire about a quarter million years ago. We just weren’t built for 24-hour diners. 

    One of the tests for diabetes is called the glucose tolerance test, which sees how fast our body can clear sugar from our bloodstream. You swig down a cup of water with about four and a half tablespoons of regular corn syrup mixed in, then have your blood sugar measured two hours later. By that point, your blood sugar should be under 140 mg/dL. Between 140 and 199 is considered to be a sign of prediabetes, and 200 and up is a sign of full-blown diabetes, as you can see in the graph below and at 1:37 in my video. 

    The circadian rhythm of glucose tolerance is so powerful that a person can test normal in the morning but as a prediabetic later in the day. Prediabetics who average 163 mg/dL at 7:00 am may test out as frank diabetics at over 200 mg/dL at 7:00 pm, as you can see in the graph below and at 1:53 in my video. 

    Choosing lower glycemic foods may help promote weight loss, but timing is critical. Due to this circadian pattern in glucose tolerance, a low-glycemic food at night can cause a higher blood sugar spike than a high-glycemic food eaten in the morning, as you can see below and at 2:05 in my video.

    We’re so metabolically crippled at night that researchers found that eating a bowl of All Bran cereal at 8:00 pm caused as high a blood sugar spike as eating Rice Krispies at 8:00 am, as you can see in the graph below and at 2:23 in my video.

    High glycemic foods at night would seem to represent the worst of both worlds. So, if you’re going to eat refined grains and sugary junk, it might be less detrimental in the morning, as you can see in the graph below and at 2:32 in my video.  

    The drop in glucose tolerance over the day could therefore help explain the weight-loss benefits of frontloading calories towards the beginning of the day. Even just taking lunch earlier versus later may make a difference, as you can see in the graph below and at 2:48 in my video.

    People randomized to eat a large lunch at 4:30 pm suffered a 46 percent greater blood sugar response compared to an identical meal eaten just a few hours earlier at 1:00 pm. A meal at 7:00 am can cause 37 percent lower blood sugars than an identical meal at 1:00 pm, as you can see below, and at 3:04 in my video.

    Now, there doesn’t seem to be any difference between a meal at 8:00 pm and the same meal at midnight; they both seem to be too late, as you can see below, and at 3:15 in my video.

    But, eating that late, at midnight or even 11:00 pm, can so disrupt your circadian rhythm that it can mess up your metabolism the next morning, resulting in significantly higher blood sugars after breakfast, compared to eating the same dinner at 6:00 pm the evening before, as shown in the graph below and at 3:32 in my video.

    So, these revelations of chronobiology bring the breakfast debate full circle. Skipping breakfast not only generally fails to cause weight loss, but it worsens overall daily blood sugar control in both diabetic individuals and people who are not diabetic, as you can see in the graph below and at 3:44 in my video.

    Below and at 3:53, you can see a graph showing how the breakfast skippers have higher blood sugars even while they’re sleeping 20 hours later. This may help explain why those who skip breakfast appear to be at higher risk of developing type 2 diabetes in the first place. 

    Breakfast skippers also tend to have higher rates of heart disease, as well as having higher rates of atherosclerosis, in general. Is this just because “skipping breakfast tends to cluster with other unhealthy choices, including smoking” and sicklier eating habits overall? The link between skipping breakfast and heart disease—even premature death in general—seems to survive attempts to control for these confounding factors, but you don’t really know until you put it to the test.

    Does skipping breakfast lead to higher cholesterol, for example? Yes, researchers found a significant rise in LDL (bad) cholesterol in study participants randomized to skip breakfast; they were about 10 points higher within just two weeks, as you can see below and at 4:45 in my video.

    The Israeli study with the caloric distribution of 700 calories for breakfast, 500 for lunch, and 200 for dinner that I’ve discussed previously found that the triglycerides of the king-prince-pauper group (those eating more at breakfast versus dinner) got significantly better—a 60-point drop—while those of the pauper-prince-king group got significantly worse (a 26-point rise). So, consuming more calories in the morning relative to the evening may actually have a triple benefit: more weight loss, better blood sugar control, and lower heart disease risk, as you can see below and at 5:18 in my video. 

    If you’re going to skip any meal, whether you’re practicing intermittent fasting or time-restricted feeding (where you try to fit all of your food intake into a certain time window each day), it may be safer and more effective to skip dinner rather than breakfast.

    I’m back with the next installment of the chronobiology series! I previously explored eating breakfast for weight loss (Is Breakfast the Most Important Meal for Weight Loss? and Is Skipping Breakfast Better for Weight Loss?), introduced chronobiology (How Circadian Rhythms Can Control Your Health and Weight), and looked at the science on eating more in the mornings than the evenings (Eat More Calories in the Morning to Lose Weight, Breakfast Like a King, Lunch Like a Prince, Dinner Like a Pauper, and Eat More Calories in the Morning Than the Evening).

    Next, you’ll see How to Sync Your Central Circadian Clock to Your Peripheral Clocks.

    The series will wrap up in the next couple of weeks. See videos and blogs in related posts below.

    Note: The Israeli 700/500/200 study that I mentioned is detailed in the Breakfast Like a King, Lunch Like a Prince, Dinner Like a Pauper video if you want to know more. Also, check the corresponding blog in related posts. 

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    Michael Greger M.D. FACLM

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  • A King’s Breakfast, a Prince’s Lunch, and a Pauper’s Dinner  | NutritionFacts.org

    A King’s Breakfast, a Prince’s Lunch, and a Pauper’s Dinner  | NutritionFacts.org

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    Harness the power of your circadian rhythms for weight loss by making breakfast or lunch your main meal of the day.

    In my last chronobiology video, we learned that calories eaten at breakfast are significantly less fattening than the same number of calories eaten at dinner, as you can see at 0:14 in my video Breakfast Like a King, Lunch Like a Prince, Dinner Like a Pauper, but who eats just one meal a day? 

    What about simply shifting our daily distribution of calories to earlier in the day? Israeli researchers randomized overweight and obese women into one of two isocaloric groups, meaning each group was given the same number of total calories. One group got a 700-calorie breakfast, a 500-calorie lunch, and a 200-calorie dinner, and the other group got the opposite—200 calories for breakfast, 500 for lunch, and 700 for dinner. Since all of the study participants were eating the same number of calories overall, the king-prince-pauper group should have lost the same amount of weight as the pauper-prince-king group, right? But, no. As you can see in the graph below and at 1:01 in my video, the bigger breakfast group lost more than twice as much weight, in addition to slimming about an extra two inches off their waistline. By the end of the 12-week study, the king-prince-pauper group lost 11 more pounds than the bigger dinner group, dropping 19 pounds compared to only 8 pounds lost by the pauper-prince-king group—despite eating the same number of calories. That’s the power of chronobiology, the power of our circadian rhythm. 

    What was the caloric distribution of the king-prince-pauper group getting 700 calories at breakfast, 500 at lunch, and 200 at dinner? They got 50 percent of calories at breakfast, 36 percent at lunch, and only 14 percent of calories at dinner, which is pretty skewed. What about 20 percent for dinner instead? A 50% – 30% – 20% spread, compared to 20% – 30% – 50%?

    Again, the bigger breakfast group experienced “dramatically increased” weight loss, a difference of about nine pounds in eight weeks with no significant difference in overall caloric intake or physical activity between the groups, as shown in the graph below and at 1:57 in my video. 

    Instead of 80 percent of calories consumed at breakfast and lunch, what about 70 percent compared to 55 percent? Researchers randomized overweight “homemakers” to eat 70 percent of their calories at breakfast, a morning snack, and lunch, leaving 30 percent for an afternoon snack and dinner, or a more balanced 55 percent from the time they woke up through lunch. In both cases, only a minority of calories were eaten for dinner, as you can see below, and at 2:25 in my video. Was there any difference between eating 70 percent of calories through lunch versus only 55 percent? Yes, those eating more calories earlier in the day had significantly more weight loss and slimming. 

    Concluded the researchers: “Stories about food and nutrition are in the news on an almost daily basis, but information can sometimes be confusing and contradictory. Clear messages should be proposed to reach the greatest number of people. One clear communication from physicians could be ‘If you want to lose weight, eat more in the morning than in the evening.’” 

    Even just telling people to eat their main meal at lunch rather than dinner may help. Despite comparable caloric intakes, participants in a weight-loss program randomized to get advice to make lunch their main meal beat out those who instead were told to make dinner their main meal.

    The proverb “Eat breakfast like a king, lunch like a prince, and dinner like a pauper” evidently has another variant: “Eat breakfast yourself, share lunch with a friend, and give dinner away to your enemy.” I wouldn’t go that far, but there does appear to be a metabolic benefit to frontloading the bulk of your calories earlier in the day.

    The evidence isn’t completely consistent, though. A review of dietary pattern studies questioned whether reducing evening intake would facilitate weight loss, citing a study that showed the evening-weighted group did better than the heavy-morning-meal group. Perhaps that was because the morning meal group was given “chocolate, cookies, cake, ice cream, chocolate mousse or donuts” for breakfast. So, chronobiology can be trumped by a junk-food methodology. Overall, the what is still more important than the when. Caloric timing may be used to accelerate weight loss, but it doesn’t substitute for a healthy diet. When he said there was a time for every purpose under heaven, Ecclesiastes probably wasn’t talking about donuts.

    When I heard about this, what I wanted to know was how. Why does our body store less food as fat in the morning? I explore the mechanism in my next video, Eat More Calories in the Morning Than the Evening.

    This is the fifth video in an 11-part series on chronobiology. If you missed the first four, check out the related posts below. 

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    Michael Greger M.D. FACLM

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  • The Pros of Garlic Powder for Heart Disease  | NutritionFacts.org

    The Pros of Garlic Powder for Heart Disease  | NutritionFacts.org

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    See what a penny a day’s worth of garlic powder can do.

    In ancient Greece, “the Art of Medicine was divided into three parts”: cures through diet, cures through drugs, and cures through surgery. Garlic, Hippocrates wrote, was one such medicinal food, but that was to treat a nonexistent entity called “displacement of the womb,” so ancient wisdom can only go so far.

    Those who eat more than a clove of garlic a day do seem to have better artery function than those who eat less than that, but you don’t know if it’s cause-and-effect until you put it to the test. 

    As I discuss in my video Benefits of Garlic Powder for Heart Disease, heart disease patients were randomized to receive either garlic powder or placebo tablets two times a day for three months. Those lucky enough to be in the garlic group got a significant boost in their artery function—a 50 percent increase in function from taking only 800 mg of garlic powder a day. That’s just a quarter teaspoon of garlic powder. A 50 percent increase in artery function for less than a penny daily!

    If regular, plain old garlic powder can do that, what about those fancy Kyolic® aged garlic extract supplements? They can be 30 times more expensive and don’t work at all. After four weeks, there was zero significant improvement. It’s hard to improve on Mother Nature.

    Garlic powder can improve the function of our arteries, but what about the structure of our arteries? Dozens of studies on garlic all compiled together show that garlic can reduce cholesterol levels in the blood by more than 16 points. So, might garlic powder actually be able to slow the progression of atherosclerosis? Researchers studied a garlic powder tablet versus a placebo for three months. As you can see below and at 1:42 in my video, the placebo group got worse, which is what tends to happen. Eat the same artery-clogging diet, and your arteries continue to clog. However, the progression of the disease appeared to slow and even stall in the garlic group. 

    Of course, it would be nice to see the thickening of the artery wall reverse, but, for that, one might have to add more plants than just garlic to one’s diet. Still, though, that same quarter teaspoon of a simple spice available everywhere may be considered as an adjunct treatment for atherosclerosis, the number one killer of both men and women in the United States and around much of the world.

    What about garlic for high blood pressure? A systematic review and meta-analysis of randomized controlled trials “demonstrated that garlic has a statistically significant and clinically meaningful effect” on both systolic and diastolic blood pressures, reducing the top number by nearly seven and the bottom number by about five. That may not sound like a lot, but reducing diastolic blood pressure (the bottom number) by five points can reduce the risk of stroke by about a third and heart disease by 25 percent, as you can see in the graph below and at 2:38 in my video. 

    “Plant-based medicine provides beneficial effects, alongside with only minimal or no complications”—that is, little or no side effects—“and compared to other medicine are relatively cost-effective.” I’d say so, at as little as a penny per day.

    What else can garlic do? See related posts below.

    Here’s a tasty, garlicky recipe from The How Not to Die Cookbook: Garlic Caesar Salad Dressing. 

    Of course, the best way to treat heart disease is to simply get rid of it by treating the underlying cause. See How Not to Die from Heart Disease.

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    Michael Greger M.D. FACLM

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  • Managing Stress and Cholesterol Levels for Better Heart Health – Aha!NOW

    Managing Stress and Cholesterol Levels for Better Heart Health – Aha!NOW

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    A healthy heart is imperative for better health. The heart requires a clear and constant blood supply to work efficiently. Both high stress levels and high cholesterol levels are detrimental as they restrict the blood supply to the heart. Moreover, there is a link between stress and cholesterol. Know more about this and how to manage their levels to keep your heart active and healthy. ~ Ed.

    Stress and high cholesterol are two common health issues that often occur together. Research shows that there is a correlation between stress and cholesterol levels – stress can contribute to high cholesterol which can in turn cause stress. By understanding their connection and taking steps to manage both stress and cholesterol, you can improve your overall health and well-being.

    The Impact of Stress on Cholesterol

    Stress triggers our bodies to produce hormones like cortisol and adrenaline. These hormones trigger a “fight or flight” response, increasing blood pressure, heart rate, and blood sugar levels. Cortisol also signals the liver to produce more cholesterol. This reaction helped our ancestors survive immediate physical threats, but modern stress is often psychological and prolonged. Chronic stress keeps cholesterol production high, causing unhealthy LDL or “bad” cholesterol levels to rise.

    High cholesterol doesn’t always cause noticeable symptoms. But over time, it can lead to a buildup of plaque in the arteries. This narrows the interior walls, restricting blood flow to the heart and brain. It increases the risk of heart attack, stroke, and other cardiovascular issues. Studies show that people with high stress often have elevated LDL cholesterol and triglyceride levels. Managing stress is key to maintaining healthy cholesterol levels and improving heart health.

    The Effects of High Cholesterol on Mental Health

    Just as stress negatively impacts cholesterol, high cholesterol can also trigger stress in a vicious cycle. High cholesterol is damaging to blood vessels everywhere, including those in the brain. Plaque buildup in cerebral arteries limits oxygen supply, which can impair cognitive skills. It also reduces the production of serotonin, an important neurotransmitter that regulates mood.

    This disruption to blood flow and brain function can cause varied neuropsychiatric symptoms. People with high LDL cholesterol often report increased anxiety, irritability, and feelings of depression. There is also an increased long-term risk of dementia. For those already dealing with mental health issues, high cholesterol presents another challenge while exacerbating existing symptoms. Knowledge of how lifestyle habits affect both the mind and body empowers people to take control of their health.

    8 Lifestyle Changes to Manage Stress and Cholesterol

    The good news is that many of the same healthy lifestyle changes can target both high cholesterol and high stress levels. Here are some practical, evidence-based ways to reduce stress while improving cholesterol profiles:

    Get Active

    Regular exercise is one of the most effective stress relievers while also lowering LDL and raising HDL cholesterol. Aim for 30-60 minutes per day of activity like brisk walking, swimming, cycling, or rowing. Yoga and Pilates can also relax the mind and strengthen the heart.

    Eat a Healthy Diet

    Limit saturated fat, trans fats, and cholesterol by eating more vegetables, fruits, whole grains, legumes, fish, and lean protein. Be sure to get ample fiber, omega-3 fatty acids, antioxidants, and probiotics. Avoid excess sugar and salt. Limit alcohol, which stresses the liver and raises triglycerides.

    Lose Excess Weight

    Carrying excess body fat, especially around the abdomen, puts more stress on the heart and promotes inflammation. Losing even 5-10% of your body weight can significantly lower cholesterol while boosting mood.

    Quit Smoking

    Smoking damages blood vessels while increasing the risk of lung disease, cancer, and heart attack. Kicking the habit reduces stress and improves cholesterol.

    Get Adequate Sleep

    Lack of sleep is linked to higher cholesterol as well as increased cortisol production. Strive for 7-9 hours per night, going to bed and waking at consistent times to regulate your circadian rhythm.

    Practice Relaxation Techniques

    Meditation, deep breathing, Tai Chi, and yoga have proven benefits for psychological stress. They activate the parasympathetic nervous system to initiate a relaxation response, lowering blood pressure and cholesterol.

    Manage Medications

    If lifestyle changes aren’t enough, cholesterol and blood pressure medications may be needed. Anti-anxiety or antidepressant drugs can also help in some cases, but their effects should be monitored. Be sure to take any prescribed drugs regularly to reduce strain on the cardiovascular system.

    Get Screened and See Your Doctor

    Have your cholesterol levels tested regularly and get screened for heart disease risk. If the numbers are very high, your doctor may recommend more aggressive treatment. Discuss any mental health concerns as well so underlying causes can be addressed.

    By relieving stress and keeping cholesterol levels in check, you can break the unhealthy cycle between mind and body. Caring for both is essential for improving heart health and enjoying a better quality of life.

    When we talk about cholesterol and liver health, it is important to know that the liver plays a central role in regulating cholesterol levels and metabolism. It removes cholesterol from the bloodstream and excretes it into bile. The liver also synthesizes cholesterol for the production of cell membranes and hormones. When we consume foods high in cholesterol and saturated fats, the liver churns out more LDL particles, which elevate cholesterol further.

    This extra burden on the liver also creates oxidative stress, compounding the negative effects. Supporting liver function through a healthy lifestyle is therefore important for maintaining normal cholesterol range and reducing cardiovascular risks.

    Conclusion

    Stress and high cholesterol often coincide, fueling each other in a destructive loop. By eating well, exercising, getting enough sleep, managing medications as needed, and implementing stress-reduction techniques, you can target both issues simultaneously. Caring for your mind and body together through a holistic approach helps relieve pressure on the heart while also enhancing mental health and wellbeing.

    Addressing stress and cholesterol through positive lifestyle changes leads to improved physical and emotional health over the long term.

    Over to you

    How do you manage your heart health? What are your tips to keep the stress and cholesterol levels under control? Share them in the comments below.

    Image credit: Freepik

    Disclaimer: We’re not offering any medical advice here. These ideas are for educational and entertainment purposes only. Always seek a professional medical opinion from a physician of your choosing before making any medical decision. The information provided here is not intended to be a substitute to the advice given by your physician or another healthcare professional.

    Disclaimer: Though the views expressed are of the author’s own, this article has been checked for its authenticity of information and resource links provided for a better and deeper understanding of the subject matter. However, you’re suggested to make your diligent research and consult subject experts to decide what is best for you. If you spot any factual errors, spelling, or grammatical mistakes in the article, please report at [email protected]. Thanks.

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    Emma Williams

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  • What the Science Says About Time-Restricted Eating  | NutritionFacts.org

    What the Science Says About Time-Restricted Eating  | NutritionFacts.org

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    Are there benefits to giving yourself a bigger daily break from eating? 
     
    The reason many blood tests are taken after an overnight fast is that meals can tip our system out of balance, bumping up certain biomarkers for disease, such as blood sugars, insulin, cholesterol, and triglycerides. Yet, as you can see in the graph below and at 0:20 in my video Time-Restricted Eating Put to the Test, fewer than one in ten Americans may even make it 12 hours without eating. As evolutionarily unnatural as getting three meals a day is, most of us are eating even more than that. One study used a smartphone app to record more than 25,000 eating events and found that people tended to eat about every three hours over an average span of about 15 hours a day. Might it be beneficial to give our bodies a bigger break? 

    Time-restricted feeding is “defined as fasting for periods of at least 12 hours but less than 24 hours,” and this involves trying to confine caloric intake to a set window of time, typically ranging from 3 to 4 hours, 7 to 9 hours, or 10 to 12 hours a day, which results in a daily fast lasting 12 to 21 hours. When mice are restricted to a daily feeding window, they gain less weight even when fed the same amount as mice “with ad-lib access.” Rodents have such high metabolisms, though, that a single day of fasting can starve away as much as 15 percent of their lean body mass. This makes it difficult to extrapolate from mouse models. You don’t know what happens in humans until you put it to the test. 
     
    The drop-out rates in time-restricted feeding trials certainly appear lower than most prolonged forms of intermittent fasting, suggesting it’s more easily tolerable, but does it work? Researchers found that when people stopped eating from 7:00 p.m. to 6:00 a.m. for two weeks, they lost about a pound each week compared to no time restriction. Note that “there were no additional instructions or recommendations on the amount or type of food consumed,” and no gadgets, calorie counting, or record-keeping either. The study participants were just told to limit their food intake to the hours of 6:00 a.m. and 7:00 p.m., a simple intervention that’s easy to understand and put into practice. 
     
    The next logical step? Put it to the test for months instead of just weeks. Obese men and women were asked to restrict eating to the eight-hour window between 10:00 a.m. and 6:00 p.m. Twelve weeks later, they had lost nearly seven pounds, as you can see in the graph below and at 2:18 in my video. This deceptively simple intervention may be operating from several different angles. People not only tend to eat more food later in the day, but eat higher fat foods later in the day. By eliminating eating in the late-evening hours, one removes prime-time snacking on the couch, a high-risk time for overeating. And, indeed, during the no-eating-after-7:00-p.m. study, the subjects were inadvertently eating about 250 fewer calories a day. Then, there are also the chronobiological benefits of avoiding late-night eating. 

    I did a whole series of videos about the role our circadian rhythms have in the obesity epidemic, how the timing of meals can be critical, and how we can match meal timing to our body clocks. Just to give you a taste: Did you know that calories eaten at dinner are significantly more fattening than the same number of calories eaten at breakfast? See the table below and at 3:08 in my video. 

    Calories consumed in the morning cause less weight gain than the same calories eaten in the evening. A diet with a bigger breakfast causes more weight loss than the same exact diet with a bigger dinner, as you can see in the graph below and at 3:21 in my video, and nighttime snacks are more fattening than the same snacks if eaten in the daytime. Thanks to our circadian rhythms, metabolic slowing, hunger, carbohydrate intolerance, triglycerides, and a propensity for weight gain are all things that go bump in the night.  


    What about the fasting component of time-restricted feeding? There’s already the double benefit of getting fewer calories and avoiding night-time eating. Does the fact that you’re fasting for 11 or 16 hours a day play any role, considering the average person may only make it about 9 hours a day without eating? How would you design an experiment to test that? What if you randomized people into two groups and had both groups eat the same number of calories a day and also eat late into the evening, but one group fasted even longer, for 20 hours? That’s exactly what researchers at the USDA and National Institute of Aging did. 
     
    Men and women were randomized to eat three meals a day or fit all of those same calories into a four-hour window between 5:00 p.m. and 9:00 p.m., then fast the rest of the day. If the weight-loss benefits from the other two time-restricted feeding studies were due to the passive calorie restriction or avoidance of late-night eating, then, presumably, both of these groups should end up the same because they’re both eating the same amount and they’re both eating late. That’s not what happened, though. As you can see below and at 4:49 in my video, after eight weeks, the time-restricted feeding group ended up with less body fat, nearly five pounds less. They got about the same number of calories, but they lost more weight. 

    As seen below and at 5:00 in my video, a similar study with an eight-hour eating window resulted in three more pounds of fat loss. So, there does seem to be something to giving your body daily breaks from eating around the clock.


    Because that four-hour eating window in the study was at night, though, the participants suffered the chronobiological consequences—significant elevations in blood pressure and cholesterol levels—despite the weight loss, as you can see below and at 5:13 in my video. The best of both worlds was demonstrated in 2018: early time-restricted feeding, eating with a narrow window earlier in the day, which I covered in my video The Benefits of Early Time-Restricted Eating. 


    Isn’t that mind-blowing about the circadian rhythm business? Calories in the morning count less and are healthier than calories in the evening. So, if you’re going to skip a meal to widen your daily fasting window, skip dinner instead of breakfast. 

    If you missed any of the other videos in this fasting series, check out the related videos below. 

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    Michael Greger M.D. FACLM

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