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Tag: heart health

  • Is Creatine Safe and Efficient for High Homocysteine?  | NutritionFacts.org

    Is Creatine Safe and Efficient for High Homocysteine?  | NutritionFacts.org

    Those on a healthy plant-based diet who have elevated homocysteine levels despite taking sufficient vitamin B12 may want to consider taking a gram a day of contaminant-free creatine.

    The average blood levels of homocysteine in men are about 1.5 points higher than in women, which may be one of the reasons men tend to be at higher risk for cardiovascular disease. Women don’t need to make as much creatine as men since they tend to have less muscle mass. That may help explain “the ‘gender gap’ in homocysteine levels.” If you remember from my previous video and as seen below and at 0:36 in The Efficacy and Safety of Creatine for High Homocysteine, in the process of making creatine, our body produces homocysteine as a by-product. So, for people with stubbornly high homocysteine levels that don’t respond sufficiently to B vitamins, “creatine supplementation may represent a practical strategy for decreasing plasma homocysteine levels”—that is, lowering the level of homocysteine into the normal range. 

    It seemed to work in rats. What about humans? Well, it worked in one study, but it didn’t seem to work in another. It didn’t work in yet another either. And, in another study, homocysteine levels were even driven up. So, this suggestion that taking creatine supplements would lower homocysteine was called into question. 

    However, all those studies were done with non-vegetarians, so they were already effectively supplementing with creatine every day in the form of muscle meat. In that way, researchers were testing higher versus lower supplementation. Those eating strictly plant-based make all their creatine from scratch, so they may be more sensitive to an added creatine source. There weren’t any studies on creatine supplementation in vegans to lower homocysteine until now. 

    Researchers took vegans who were not supplementing their diets with vitamin B12, so some of their homocysteine levels were through the roof. A few were as high as 50 when the ideal is more like under 10, for example. After taking some creatine for a few weeks, all of their homocysteine levels normalized. You can see the before and after in the graph below and at 2:04 in my video. 

    Now, they didn’t normalize, as that would have been a level under 10, but that’s presumably because they weren’t taking any B12. Give vegetarians and vegans vitamin B12 supplements, either dosing daily or once a week, and their levels normalize in a matter of months, as you can see below and at 2:20 in my video. However, the fact that you could bring down homocysteine levels with creatine alone, even without any B12, suggests—to me at least—that if your homocysteine is elevated (above 10) on a plant-based diet despite taking B12 supplements and eating greens and beans to get enough folate, it might be worth experimenting with supplementing with a gram of creatine a day for a few weeks to see if your homocysteine comes down. 

    Why just a single gram? That’s approximately how much non-vegetarians do not have to make themselves; it’s the amount that erased vegetarian discrepancies in blood and muscle, as you can see in the graph below and at 3:01 in my video, and how much has been shown to be safe in the longer term. 

    How safe is it? We can take a bit of comfort in the fact that it’s “one of the world’s best-selling dietary supplements,” with literally billions of servings taken, and the only consistently reported side effect has been weight gain, presumed to be from water retention. The only serious side effects appear to be among those with pre-existing kidney diseases taking whopping doses closer to 20 grams a day. A concern was raised that creatine could potentially form a carcinogen known as N-nitrososarcosine when it hit the acid bath of the stomach, but, when it actually put to the test, researchers found this does not appear to be a problem. 

    Bottom line: Doses of supplemental creatine up to 3 grams a day are “unlikely to pose any risk,” provided “high purity creatine” is used. However, as we all know, dietary supplements in the United States “are not regulated by the US Food and Drug Administration and may contain contaminants or variable quantities of the desired supplement” and may not even contain what’s on the label. We’re talking about “contaminants…that may be generated during the industrial production.” When researchers looked at 33 samples of creatine supplements made in the United States and Europe, they found that they all actually contained creatine, which is nice, but about half exceeded the maximum level recommended by food safety authorities for at least one contaminant. The researchers recommend that “consumers give their preference to products obtained by producers that ensure the highest quality control and certify the maximum amount of contaminants present in their products.” Easier said than done.

    Because of the potential risks, I don’t think people should take creatine supplements willy-nilly, but the potential benefits may exceed the potential risks if, again, you’re on a healthy plant-based diet and taking B12, and your homocysteine levels are still not under 10. In that case, I would suggest giving a gram a day of creatine a trying to see if it brings it down.

    The reason I did this whole video series goes back to “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,” which found that, although the overall cardiovascular risk is lower in vegetarians and vegans combined, they appeared to be at slightly higher stroke risk, as you can see in the graph below and at 5:06 in my video. 

    I went through a list of potential causes, as you can see at 5:11 and below, and arrived at elevated homocysteine. What’s the solution? A regular, reliable source of vitamin B12. The cheapest, easiest method that I personally use is one 2,500 mcg chewable tablet of cyanocobalamin, the most stable source of B12, once a week. (In fact, you can just use 2,000 mcg once a week.) And, again, a backup plan for those doing that but still having elevated homocysteine is an empirical trial of a single gram a day of creatine supplementation, which was shown to improve at least capillary blood flow in those who started out with high homocysteine levels. 

    In sum, plant-based diets appear to “markedly reduce risk” for multiple leading killer diseases—heart disease, type 2 diabetes, and many common types of cancer—but “an increased risk for stroke may represent an ‘Achilles heel.’ Nonetheless, vegans have the potential to achieve a truly exceptional ‘healthspan’ if they face this problem forthrightly by restricting salt intake and taking other practical measures that promote cerebrovascular [brain artery] health…Nonetheless, these considerations do not justify nutritional nihilism. On balance, low-fat vegan diets offer such versatile protection for long-term health that they remain highly recommendable. Most likely, the optimal strategy is to adopt such a [plant-based] diet, along with additional measures—appropriate food choices, exercising training, judicious supplementation [of vitamin B12]—that will mitigate the associated stroke risk.” And try not to huff whipped cream charging canister gas. Leave the “whippets” alone.

    This concludes my series on stroke risk. If you missed any of the other videos, see the related posts below.

    I’m assuming that nearly everyone taking their B12 will have normal homocysteine levels, so these last two videos are just for the rare person who doesn’t. However, those on a healthy plant-based diet with elevated homocysteine levels despite taking sufficient vitamin B12 should consider taking a gram a day of contaminant-free creatine, which should be about a quarter teaspoon.

    Where do you get contaminant-free creatine? Since regulations are so lax, you can’t rely on supplement manufacturers no matter what they say, so I would recommend going directly to the chemical suppliers that sell it to laboratories and guarantee a certain purity. Here are some examples (in alphabetical order) of some of the largest companies where you can get unadulterated creatine: Alfa Aesar, Fisher Scientific, Sigma-Aldrich, and TCI America.

    Michael Greger M.D. FACLM

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  • These Are 4 of the Most Common Complications of Hypertrophic Cardiomyopathy

    These Are 4 of the Most Common Complications of Hypertrophic Cardiomyopathy

    You could argue that the complications of a disease, rather than the disease itself, create most of the problems associated with that condition. Take hypertrophic cardiomyopathy, or HCM, a primarily genetic condition that results in a thickening of the walls of the heart—specifically its left ventricle, which is the chamber that pumps blood out of the heart and into the aorta. According to the Hypertrophic Cardiomyopathy Association, HCM is the most common genetic heart condition, affecting at least 1 in every 500 adults—possibly more, given that as many as half of all people with the disorder have no symptoms or ones that are so mild, they go unnoticed.

    The American Heart Association (AHA) reports that about two-thirds of those who have been diagnosed with HCM have so much thickening in their heart muscle that it obstructs blood flow out of the left ventricle and into the aorta. This is called, aptly, obstructive hypertrophic cardiomyopathy. This kind of obstruction is behind many of the more troublesome and life-threatening complications of HCM.

    In nonobstructive HCM, the thicker muscles may mean the ventricle is less able to pump the normal volume of blood, but the blood is able to move in and out of the ventricle unimpeded. Most people who have the nonobstructive version of the disease will have milder symptoms and lower risk of death than those with its obstructive relative. In other words, they’re likely to have fewer, though by no means zero, complications of their disease.

    With that in mind, here’s a look at what to know about four of the most common HCM complications—including how they manifest and how they’re treated.

    Atrial fibrillation (AFib)

    There are two main types of heart arrhythmias, and you’re probably already familiar with one of them: atrial fibrillation, or AFib. It describes a rapid and irregular heartbeat that can lead to blood clots within the heart, which, in turn, can increase the risk of stroke. “The longer a patient has the condition, the more likely atrial fibrillation is to occur,” says Dr. Steve Ommen, director of the Hypertrophic Cardiomyopathy Clinic at the Mayo Clinic in Rochester, Minn.

    AFib shows up in about a quarter of people with HCM. However, Dr. Milind Desai, director of the Hypertrophic Cardiomyopathy Center and vice chair of the Heart, Vascular and Thoracic Institute at the Cleveland Clinic, says that estimate may be too low. “I don’t believe we have accurate data,” he notes, “as many patients have short bursts of AFib that are asymptomatic.” In these instances, the heart beats irregularly, but the person feels none of the usual symptoms to warn them of the arrhythmia.

    Those who do experience symptoms might report heart palpitations or a sense of a rapidly pounding heart, shortness of breath, dizziness, or fainting. Treatment often focuses on the use of anticoagulant drugs, which prevent the formation of the blood clots that can lead to stroke. Cardiologists may also recommend drugs to restore a more normal heartbeat, including beta blockers or calcium channel blockers, which work by lowering the heart’s pumping rate and giving the cardiac muscles a bit of a biological break.

    When AFib recurs or doesn’t respond to medications, a minimally invasive procedure known as cardiac ablation may be considered. It involves using heat or cold to create very small scars in the heart tissue to interrupt the abnormal electrical signals that lead to the rapid or irregular heartbeat.

    Read More: What to Know About Hypertrophic Cardiomyopathy in Kids

    Ventricular tachycardia (VT)

    Ventricular tachycardia is another type of abnormal heart rhythm, in which an extremely fast heartbeat begins in the lower chambers of the heart. The rapidity of the beat prevents the ventricles from filling with enough blood before they contract again.

    The symptoms of ventricular tachycardia are similar to those of AFib and include palpitations, dizziness, shortness of breath, and fainting, but may also include neck tightness, chest pain, and even cardiac arrest. As with AFib, a cardiologist might prescribe beta blockers or calcium channel blockers to treat the symptoms and control the heart’s rhythm. When people don’t respond to medication, or if they have particularly advanced VT, they may need an implantable defibrillator. That’s “a special pacemaker-like device to monitor the heart for dangerous arrhythmias and deliver an electric shock to reset the heart to a normal rhythmif they occur,” says Dr. Michelle Kittleson, director of education in heart failure and transplantation and professor of medicine at the Smidt Heart Institute at Cedars-Sinai in Los Angeles.

    Compared to atrial fibrillation, VT packs a much bigger cardiac punch. “In terms of risk, ventricular tachycardia is the one we screen for annually in HCM,” Ommen says. “Ventricular tachycardia itself can make the squeezing function of the left ventricle ineffective; it can also degenerate into ventricular fibrillation.” While VT is about a rapid heartbeat, the problem in ventricular fibrillation, or VF, is that the ventricles contract in a sort of quivering and random beat. The AHA calls VF the “most serious abnormal heart rhythm,” and notes that, without treatment, it can lead to sudden cardiac death within minutes.

    Kittleson agrees. “Ventricular arrhythmias are more dangerous,” she says, “because they can cause sudden cardiac death, as the heart cannot pump efficiently and no blood gets to the body.” In fact, VT that becomes ventricular fibrillation is the most common cause of sudden cardiac death.

    Heart failure

    Another common HCM complication is heart failure, a broad term that means your heart isn’t able to pump enough blood out into your circulation to properly oxygenate the rest of your body. The heart fails, in other words, to effectively do its most essential job. Heart failure is not, however, the same thing as cardiac arrest, which is when the heart stops—arrests—its beating altogether.

    In HCM, heart failure is generally a result of the thickening and stiffening of the heart’s ventricles. In that sense, according to the Hypertrophic Cardiomyopathy Association, HCM is simply a form of heart failure. Specifically, people with HCM tend to develop a type of heart failure in which the left ventricle can’t fill with enough blood—because of its overly muscular walls—to then pump sufficient blood throughout the body. With less blood in the ventricle in the first place, even a perfectly pumping heart won’t be able to force as much blood out into the circulation as it’s meant to. And a heart with walls thickened by HCM is unlikely to be a perfectly pumping heart.

    Still, Desai notes, not all HCM patients experience heart failure. “Many HCM patients can be asymptomatic,” he says. “But if you have shortness of breath due to a cardiac problem, technically you have some element of heart failure.”

    In addition to an inadequate supply of oxygenated blood in the body, heart failure tends to lead to an accumulation of fluid in the body’s tissues, which is called congestive heart failure. In addition to the obvious physical signs of fluid accumulation, like swollen ankles, there are the more subtle and potentially dangerous ones. Fluid from the processes of heart failure is especially prone, for instance, to build up in the lungs; this can lead to coughing and shortness of breath, generalized symptoms that aren’t always as benign as they may initially seem.

    The treatment of heart failure itself—rather than the disease that causes heart failure, like HCM—tends to focus on the treatment of congestive heart failure, specifically. Cardiologists will likely prescribe diuretics, drugs meant to help the body’s kidneys process the extra fluid. Patients might be asked to limit both time on feet and fluid intake. The same beta blockers and calcium channel blockers used to treat arrhythmias can also be used to slow the heart enough to allow the left ventricle to fill to the best of its ability. For those with the most severe forms of heart failure, heart transplantation may be the best option.

    Read More: 9 Weird Symptoms Cardiologists Say You Should Never Ignore

    Sudden cardiac death

    Sometimes the first—and, sadly, last—sign of HCM is also its most feared complication. Sudden cardiac death, which is also known as sudden cardiac arrest, occurs when the heart stops beating or beats so irregularly or weakly that it can no longer provide enough oxygen to the body to sustain life. A death falls under the sudden cardiac death label if it occurs within an hour of the onset of symptoms such as feeling faint, dizzy, or noticing the feeling of an irregular heartbeat—in other words, the signs of ventricular fibrillation. If the heart actually stops beating, however, death will occur within minutes, unless emergency measures are taken.

    Experts stress that sudden cardiac death—which, in HCM, occurs when the heart’s electrical system misfires, resulting in ventricular tachycardia or ventricular fibrillation—is not the same as a heart attack, in which a blocked artery prevents blood from getting to the heart, killing off the heart’s muscles.

    HCM is one of the most common identifiable causes of sudden cardiac death in athletes under 35. And although it is by no means a common outcome for those with HCM, sudden cardiac death occurs in approximately 0.8% of affected individuals each year, says Ommen. “Assessing each individual’s risk is thus an important part of regular checkups,” he notes.

    The cascade to sudden cardiac death can be treated, if caught immediately after its onset, using CPR to keep blood flowing through the body, an external defibrillator to reset the heart rhythm, and medications to restore the heart’s normal rhythms.

    Read More: How to Talk to Your Family About Their Heart Health History

    Better still, cardiologists say, is to treat the arrhythmias and other electrical-impulse issues that can arise in an individual with HCM—or to treat the HCM itself—sand thereby stave off sudden cardiac death altogether.

    Overall, says Kittleson, it’s important to remember that “HCM is not a death sentence. With current methods of diagnosis, evaluation, and treatment, survival is comparable to that of the general population. With proper management, patients can live full and healthy lives.”

    Lori Oliwenstein

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  • Creatinine to Normalize Homocysteine in Vegetarians?  | NutritionFacts.org

    Creatinine to Normalize Homocysteine in Vegetarians?  | NutritionFacts.org

    What are the consequences of having to make your creatine rather than relying on dietary sources?

    “Almost universally, research findings show a poor vitamin B12 status among vegetarians” because they aren’t taking vitamin B12 supplements like they should, which results in an elevation in homocysteine levels. This may explain why vegetarians were recently found to have higher rates of stroke, as you can see in the graph below and at 0:30 in my video Should Vegetarians Take Creatine to Normalize Homocysteine?.

    Of course, plant-based eating is just one of many ways to become deficient in vitamin B12. Even nitrous oxide (laughing gas) can do it in as little as two days, thanks to the recreational use of whipped cream canister gas. (I just learned about “whippits”!)

    When researchers gave vegetarians and vegans as little as 50 daily micrograms of cyanocobalamin, which is the recommended and most stable form of vitamin B12 supplement, their homocysteine levels, which had started up in the elevated zone, normalized right down into the safe zone under 10 mmol/L within only one to two months. Just 2,000 micrograms of cyanocobalamin once a week gave the same beautiful result, as you can see in the graph below and at 1:15 in my video. 

    Not always, though. In another study, even 500 daily micrograms, taken as either a sublingual chewable or swallowable regular B12 supplement, didn’t normalize homocysteine within a month, as shown below and at 1:24. Now, presumably, if the participants had kept it up, their levels would have continued to fall as they did in the 50-daily-microgram study.

    If you’re plant-based and have been taking your B12, but your homocysteine level is still too high (above 10 mmol/L), is there anything else you can do? Well, inadequate folate intake can also increase homocysteine, but folate comes from the same root as foliage. It’s found in beans and leaves, concentrated in greens. If you’re eating beans and greens, taking your B12, and your homocysteine level is still too high, I’d suggest taking 1 gram of creatine a day as an experiment, then getting your homocysteine levels retested in a month to see if it helped.

    Creatine is a compound formed naturally in the human body that is primarily involved with energy production in our muscles and brain. It’s also formed naturally in the bodies of many other animals. So, when we eat their muscles, we can also take in some of the creatine in their bodies through our diet. We only need about 2 grams of creatine a day, so those who eat meat may get about 1 gram from their diet and their body makes the rest from scratch. There are rare birth defects where you’re born without the ability to make it, in which case, you have to get it from your diet. Otherwise, our bodies can make as much as we need to maintain normal concentrations in our muscles.

    As you can see in the graph below and at 2:54 in my video, when you cut out meat, the amount of creatine floating around in your bloodstream goes down.

    However, the amount in your brain remains the same, as shown in the graph below and at 2:57. This shows that dietary creatinine doesn’t influence the levels of brain creatine, because our brain makes all the creatine we need. The level in vegetarian muscles is lower, but that doesn’t seem to affect exercise performance, as both vegetarians and meat eaters respond to creatine supplementation with similar increases in muscle power output. If vegetarian muscle creatine were insufficient, then presumably an even bigger boost would be seen. So, all that seems to happen when we eat meat is that our body doesn’t have to make as much. What does all of this have to do with homocysteine?

    As you can see below and at 3:36 in my video, in the process of making creatine, our body produces homocysteine as a waste product. Now, normally this isn’t a problem because our body has two ways to detoxify it: by using vitamin B6 or a combination of vitamin B12 and folate. Vitamin B6 is found in both plant and animal foods, and it’s rare to be deficient. But, vitamin B12 is mainly found in animal foods, so its level can be too low in those eating plant-based who don’t also supplement or eat B12-fortified foods. And, as I mentioned, folate is concentrated in plant foods, so it can be low in those who don’t regularly eat greens, beans, or folic-acid-fortified grains. Without that escape valve, homocysteine levels can get too high. However, if you’re eating a healthy plant-based diet and taking your B12 supplement, your homocysteine levels should be fine. 

    What if they aren’t? We might predict that if we started taking creatine supplements, our level of homocysteine might go down since we won’t have to make so much of it from scratch, producing homocysteine as a by-product, but you don’t know until you put it to the test. I’ll cover that next. 

    This is the eleventh in a 12-video series exploring stroke risk. If you missed the last two, see Vegetarians and Stroke Risk Factors: Vitamin B12 and Homocysteine? and How to Test for Functional Vitamin B12 Deficiency.

    This whole creatine angle was new to me. I had long worried about homocysteine levels being too high among those getting inadequate B12 intake, but I didn’t realize there was another potential mechanism for bringing it down other than with vitamin B. Let’s see if it pans out in my final video of the series: The Efficacy and Safety of Creatine for High Homocysteine. 

    Michael Greger M.D. FACLM

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  • Testing for Vitamin B12 Deficiency  | NutritionFacts.org

    Testing for Vitamin B12 Deficiency  | NutritionFacts.org

    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. 

    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

    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: 

    Michael Greger M.D. FACLM

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  • What About Animal Protein and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Animal Protein and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    Might animal protein-induced increases in the cancer-promoting growth hormone IGF-1 help promote brain artery integrity? 

    In 2014, a study on stroke risk and dietary protein found that greater intake was associated with lower stroke risk and, further, that the animal protein appeared particularly protective. Might that help explain why, as shown in the graph below and at 0:31 in my video Vegetarians and Stroke Risk Factors: Animal Protein?, vegetarians were recently found to have a higher stroke rate than meat eaters?

    Animal protein consumption increases the levels of a cancer-promoting growth hormone in the body known as IGF-1, insulin-like growth factor 1, which “accelerates the progression of precancerous changes to invasive lesions.” High blood concentrations are associated with increased risks of breast, colorectal, lung, and prostate cancers, potentially explaining the association between dairy milk intake and prostate cancer risk, for example. However, there are also IGF-1 receptors on blood vessels, so perhaps IGF-1 promotes cancer and brain artery integrity.

    People who have strokes appear to have lower blood levels of IGF-1, but it could just be a consequence of the stroke rather than the cause. There weren’t any prospective studies over time until 2017 when researchers found that, indeed, higher IGF-1 levels were linked to a lower risk of stroke—but is it cause and effect? In mice, the answer seems to be yes, and in a petri dish, IGF-1 appears to boost the production of elastin, a stretchy protein that helps keep our arteries elastic. As you can see in the graph below and at 1:41 in my video, higher IGF-1 levels are associated with less artery stiffness, but people with acromegaly, like Andre the Giant, those with excessive levels of growth hormones like IGF-1, do not appear to have lower stroke rates, and a more recent study of dietary protein intake and risk of stroke that looked at a dozen studies of more than half a million people (compared to only seven studies with a quarter million in the previous analysis), found no association between dietary protein intake and the risk of stroke. If anything, dietary plant protein intake may decrease the risk of stroke. 

    However, those with high blood pressure who have low IGF-1 levels do appear to be at increased risk of developing atherosclerosis, which is the thickening of the artery walls leading up to the brain, but no such association was found in people with normal blood pressure. So, there may be “a cautionary lesson for vegans” here. Yes, a whole food, plant-based diet “can down-regulate IGF-1 activity” and may slow the human aging process, not to mention reduce the risk of some of the common cancers that plague the Western world. But, “perhaps the ‘take-home’ lesson should be that people who undertake to down-regulate IGF-1 activity [by cutting down on animal protein intake] as a pro-longevity measure should take particular care to control their blood pressure and preserve their cerebrovascular health [the health of the arteries in their brain] – in particular, they should keep salt intake relatively low while insuring an ample intake of potassium” to keep their blood pressures down. So, that means avoiding processed foods and avoiding added salt, and, in terms of potassium-rich foods, eating beans, sweet potatoes, and dark-green leafy vegetables. 

    Might this explain the higher stroke risk found among vegetarians? No—because dairy and egg whites are animal proteins, too. Only vegans have lower IGF-1 levels in both men and women, so low levels of IGF-1 can’t explain why higher rates of stroke were found in vegetarians. Then what is it? I think the best explanation for the mystery is something called homocysteine, which I cover next. 

    If you aren’t familiar with IGF-1, my videos Flashback Friday: Animal Protein Compared to Cigarette Smoking and How Not to Die from Cancer are good primers. 

    Beyond eating a plant-based diet, how else can we lower our blood pressure? Check out the chapter of hypertension in my book How Not to Die at your local public library. 

    This is the eighth video in a 12-part series on vegetarians’ stroke risk. If you missed any of the previous ones, check out the related posts below.

    Coming up, we turn to what I think is actually going on:

    Michael Greger M.D. FACLM

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

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

    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.

    Michael Greger M.D. FACLM

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  • 9 Weird Symptoms Cardiologists Say You Should Never Ignore

    9 Weird Symptoms Cardiologists Say You Should Never Ignore

    If a middle-aged man starts clutching his chest, sweating profusely, and gasping for air, everyone knows he’s probably having a heart attack. It’s the “Bollywood drama” depiction of heart problems, says Dr. Basel Ramlawi, a cardiothoracic surgeon with Main Line Health in Philadelphia. “It’s the most dramatic way—but not the most common way—in which patients present.”

    Heart problems can actually be quite subtle, he clarifies, and they tend to show up differently in everyone. While someone having a heart attack might, in fact, grab their chest, others—especially women and people with diabetes, who often have nerve damage that prevents them from feeling pain—won’t necessarily experience any chest discomfort at all. Other heart conditions can appear in equally varied ways.

    There’s good reason to pay attention to even the most understated symptoms: “Your heart is the lifeline of your whole body,” Ramlawi says. “It’s the pump that supplies blood to every other organ in the body, and if it doesn’t work well, then the fuel that supplies the rest of the body isn’t getting to where it needs to be.”

    With that in mind, we asked cardiologists to share the weird symptoms that patients often brush off—but which could actually signal a serious heart problem.

    A sinking feeling in your chest

    People who have experienced heart palpitations describe their symptoms in interesting and wide-ranging ways, says Dr. Edo Paz, a cardiologist at White Plains Hospital in New York and senior vice president of medical affairs with the app Hello Heart. Some say it feels like a goldfish is flipping around in their chest. Others report a sinking feeling. “Imagine that feeling when you’re in an elevator and it starts to descend quickly, and everything drops,” he says.

    Read More: How to Prevent and Treat Hemorrhoids, According to Doctors

    Even if you’re tempted to brush off the strange sensations, it’s important to bring them up with your doctor, who will likely do an EKG and send you home with a heart monitor. It’s possible you could have a heart rhythm disorder like atrial fibrillation, or Afib. “When we’re trying to evaluate palpitations, we want to identify whether there’s an actual arrhythmia underneath it,” Paz says. “An arrhythmia is not a symptom. That’s a diagnosis.” He suggests keeping a log of when you experience palpitations, as well as what might have triggered them: a fight with your spouse? Exercising? Many of his patients also take advantage of the ECG feature on their smartwatch, which provides useful data for their doctors.

    Whooshing in the ear

    If you have pulsatile tinnitus, you’ll hear rhythmic sounds—like whooshing or thumping—in one or both ears. Annoying, right? It’s also an atypical heart symptom, says Dr. Heather Gornik, a cardiologist and vascular medicine specialist who’s a professor in the school of medicine at Case Western Reserve University. “Sometimes there are peripheral symptoms that one wouldn’t think are cardiovascular at all that could be a manifestation of cardiovascular disease,” she says. “And the one I see the most is patients who have a pulsating sound in the ear,” often in tune with their heartbeat. 

    That sound can signal carotid artery stenosis—narrowing of the blood vessels that carry blood from the heart to the brain—or the rare vascular disease fibromuscular dysplasia. The latter affects women more than 90% of the time, Gornik says, and can be associated with artery blockages and tears, as well as aneurysms. “People hear this pulsating sound, and they think nothing of it,” Gornik says. “But it’s something that needs to be taken pretty seriously.” If you’re suddenly experiencing new and persistent whooshing in your ear, call your doctor, she urges.

    Pain or fatigue in the legs while walking

    Notice you’re not able to walk as far anymore, or that your legs feel tired or painful as you plod along? Don’t ignore it. “The legs have a lot of clues about the cardiovascular system,” Gornik says. A condition called peripheral artery disease (PAD), for example, occurs when the arteries that carry blood from the heart to the legs get clogged; it’s associated with an increased risk of heart attack, stroke, and early death. “That can manifest with leg pain while walking, or just tiredness in the leg, and it’s important to identify the condition,” she says.

    Read More: 6 Health Myths About Oils

    If your symptoms persist for a week or two, see your doctor, Gornik suggests. They’ll likely do a physical exam and an ankle-brachial index test, which measures blood pressure in your legs and arms. “PAD can be a serious condition that could lead to amputation,” Gornik says. “But also, if you have it, it means you likely have heart artery blockages, so you need to have your heart managed appropriately, too.”

    Changes in your feet or legs

    Swollen feet, legs, and ankles—often called peripheral edema—can be a telltale sign of congestive heart failure. Blame it on gravity: When the heart is unable to pump blood effectively because it’s too weak, that blood drops to the lowest part of the body and gets trapped there, Ramlawi explains. So when should you see a doctor? “If it’s in both feet, not just one, and it comes back the next day or the day after,” it’s time to investigate what’s causing it, he says.

    It’s also smart to keep an eye out for “abrupt color changes,” Gornik points out. In addition to causing your leg or legs to swell up, blood clots could turn them purple or, in some cases, “totally pale and white.” Blood clots are a medical emergency in their own right—and can lead to heart attack and stroke—so if you notice these changes, seek treatment right away, she urges.

    Jaw or neck pain with exertion

    Angina—the technical name for chest tightness—can spread to the jaw or neck. It’s typically triggered by exertion, like walking uphill, or emotional stress, says Dr. William Zoghbi, chair of cardiology at Houston Methodist. “It radiates,” he says. “You’re going to localize it most often in the upper extremities. People think about the arm, but they don’t think about the jaw or neck as often.” If your pain or discomfort is triggered by exertion and relieved by rest, or if it comes and goes, get it checked out, Zoghbi advises. Your doctor will likely do a stress test and run imaging to figure out if you have a condition putting you at heightened risk of a heart attack or stroke.

    Indigestion and nausea

    After having a heavy meal, you might experience chest discomfort “or a lot of belching,” Zoghbi says. It was definitely the spicy tacos, right? Not so fast: Chest pain that’s similar to indigestion or heartburn can signal ischemic heart disease, he says. Though people often dismiss it as a run-of-the-mill gastrointestinal symptom, it’s best to monitor it closely—and, if it gets worse or doesn’t go away, to call your doctor.

    Read More: 7 Metrics Everyone Should Know About Their Own Health

    It’s also important to pay close attention to nausea. For both men and women, the most common heart-attack symptoms are chest pain and shortness of breath. “But women are much more likely than men to present with what we call atypical symptoms,” Paz says. That includes nausea, which you should take particularly seriously if you’re also experiencing jaw or back pain, lightheadedness, or unusual fatigue.

    Carpal tunnel discomfort paired with shortness of breath

    If you’re experiencing carpal tunnel symptoms, you might notice your wrist hurts after typing on your work laptop; maybe you get a “pins and needles” feeling in your fingers, or hand weakness that makes it tough to grip your dog’s leash. Especially when accompanied by shortness of breath, these symptoms can indicate cardiac amyloidosis, Zoghbi says. “It’s a problem of protein misfolding,” he explains. “The protein, which is called amyloid, starts depositing in different parts of the body. It can deposit in the heart, in neurological areas, and in the area of the carpal tunnel.” The good news, Zoghbi adds, is that there’s now effective treatment for the condition; 10 years ago, that wasn’t the case.

    Sudden stabbing chest pain

    Classic chest pain typically feels like pressure, fullness, or squeezing, and it often gets worse with exertion and then goes away before coming back again later. People who are experiencing aortic dissection, meanwhile—a tear in one of the body’s major arteries—describe sudden, stabbing pain in the middle of the chest that radiates to their back. It can be lethal if not caught in time, Ramlawi stresses. “If this goes unrecognized for just one day, close to 25% to 50% of people would be dead,” he says. “We usually put them in a chopper and transfer them to a big emergency center where they undergo immediate open heart surgery.” If detected quickly, there’s a good survival rate, he adds. “The problem is that oftentimes, patients don’t recognize it. They brush it off as something else, and they stay home and don’t come to the hospital.” If you experience this kind of stabbing pain, treat it as an emergency.

    Read More: How to Get Your Partner to Stop Snoring

    Trouble with daily activities

    Valvular disease is a growing focus area in the diagnosis and treatment of heart disease, says Dr. Charles Davidson, an interventional cardiologist who’s vice chair of clinical affairs in the department of medicine at Northwestern University Feinberg School of Medicine. While coronary disease occurs when the arteries that supply the heart become blocked, valvular disease indicates that the heart’s valves aren’t working well. Unlike a sudden cardiac event—say, a heart attack—valvular disease develops slowly, over five to 10 years. Many patients don’t experience symptoms until later in the course of disease, if at all, Davidson says.

    Those who do detect something is off often report that they’re “feeling a little older, or a little more tired,” he adds. “They don’t really think much of it.” Yet, perhaps without even noticing, they cut back on their activities or make tweaks to the way they approach their daily routine. When a doctor asks if they can walk up two flights of stairs, someone with valvular disease might respond: “Well, sure. But I have to stop after the first flight.” Or maybe the question is about whether they can clean the whole house. Davidson often sees people reply in the affirmative—but when he asks if they can do it all at once, they say no, they have to take breaks.

    Pointing out these changes to everyday abilities is essential, Davidson says, because the earlier doctors figure out there’s a problem, the faster they can treat it. “Don’t wait until you feel awful,” he stresses. “Get on it early—if nothing else, [your screening test] will be reassuring.” Therapies have markedly evolved in recent years, he adds, and so far this year, he’s successfully treated two men over age 100—meaning factors like age are no longer an automatic deterrent to overcoming a heart problem.

    Angela Haupt

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  • Science Give Marijuana Users Some Good Heart News

    Science Give Marijuana Users Some Good Heart News

    Science continues to prove cannabis has medical benefits…and more people are acknowledging the value of the plant

    As the debate about marijuana being rescheduled continues, science continues to prove cannabis has medical benefits. While more research needs to be done in a variety of areas, medical organizations are coming around to the data regarding the plant’s help in medical conditions. And now science give marijuana users some good heart news.

    Heart disease is the leading cause of death of women, men, and people of most racial and ethnic groups. Known as the silent killer, it can strike without advance notice, killing over 600,000 in the US and Canada alone. But science has come a long way in matter of open heart surgery and other key elements around heart health.

    RELATED: What We Know About Medical Marijuana’s Effect On Heart Disease

    Despite the negative perception about cannabis, it is alcohol which aggravates cardio problems. Heavy drinking is linked to heart conditions. Excessive alcohol intake can lead to high blood pressure, heart failure or stroke. It can also contribute to cardiomyopathy, a disorder that affects the heart muscle.

    Photo by LPETTET/Getty Images

    While heavy marijuana use can cause complications with the cardiovascular system, it seems light to moderate use can have a least one benefits.  A study conducted by the American Heart Association shows cannabis users had a lower risk of A-fib. Researchers compared the health, length of hospital stay and mortality rates of cannabis users and non-users.

    They observed significantly reduced odds of atrial fibrillation (Afib) among cannabis users.  Not only that, patients who were cannabis users were also less likely to die in the hospital. Also surprising to researchers was the fact that cannabis users also had shorter hospital stays than non-cannabis users. 

    AFib is an irregular and often very rapid heart rhythm. An irregular heart rhythm is called an arrhythmia. AFib can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other heart-related complications.The intensive study revealed contrary to some pronouns evidence, the large prospective cohort study failed to reveal any evidence that cannabis use was associated with an increased risk of A-fib.

    Despite the good news, more research needs to be done and the federal government needs to recognize the benefits of the plant. Only then will it become part of the mainstream treats of heart disease, cancer and more. 

    Amy Hansen

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  • What About Vegan Junk Food and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Vegan Junk Food and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    Just because you’re eating a vegetarian or vegan diet doesn’t mean you’re eating healthfully.

    “Plant-Based Diets Are Associated with a Lower Risk of Incident Cardiovascular Disease, Cardiovascular Disease Mortality, and All-Cause Mortality in a General Population of Middle-Aged Adults”: This study of a diverse sample of 12,000 Americans found that “progressively increasing the intake of plant foods by reducing the intake of animal foods is associated with benefits on cardiovascular health and mortality.” Still, regarding plant-based diets for cardiovascular disease prevention, “all plant foods are not created equal.” As you can see in the graph below and at 0:40 in my video Vegetarians and Stroke Risk Factors: Vegan Junk Food?, a British study found higher stroke risk in vegetarians. Were they just eating a lot of vegan junk food? 

    “Any diet devoid of animal food sources can be claimed to be a vegetarian [or vegan] diet; thus, it is important to determine” what is being eaten. One of the first things I look at when I’m trying to see how serious a population is about healthy eating is something that is undeniably, uncontroversially bad: soda, aka liquid candy. Anyone drinking straight sugar water doesn’t have health on top of mind.

    A large study was conducted of plant-based eaters in the United States, where people tend to cut down on meat for health reasons far more than for ethics, as you can see in the graph below and at 1:20 in my video.

    Researchers found that flexitarians drink fewer sugary beverages than regular meat eaters, as do pescatarians, vegetarians, and vegans, as you can see below and at 1:30.

    However, in the study from the United Kingdom where the increased stroke risk in vegetarians was found and where people are more likely to go veg or vegan for ethical reasons, researchers found that pescatarians drink less soda, but the vegetarians and vegans drink more, as shown in the graph below and at 1:44. 

    I’m not saying that’s why they had more strokes; it might just give us an idea of how healthfully they were eating. In the UK study, the vegetarian and vegan men and women ate about the same amounts of desserts, cookies, and chocolate, as you can see in the graph below and at 1:53. 

    They also consumed about the same total sugar, as shown below and at 2:02. 

    In the U.S. study, the average non-vegetarian is nearly obese, the vegetarians are a little overweight, and the vegans were the only ideal weight group. In this analysis of the UK study, however, everyone was about the same weight. The meat eaters were lighter than the vegans, as you can see below, and at 2:19 in my video. The EPIC-Oxford study seems to have attracted a particularly “health-conscious” group of meat eaters weighing substantially less than the general population. 

    Let’s look at some specific stroke-related nutrients. Dietary fiber appears to be beneficial for the prevention of cardiovascular disease, including stroke, and it seems the more, the better, as you can see in the graph below and at 2:43 in my video. 

    Based on studies of nearly half a million men and women, there doesn’t seem to be any upper threshold of benefit—so, again, “the more, the better.” At more than 25 grams of soluble fiber and 47 grams of insoluble dietary fiber, you can start seeing a significant drop in associated stroke risk. So, one could consider these values “as the minimal recommendable daily intake of soluble and insoluble fiber…to prevent stroke at a population level.” That’s what you see in people eating diets centered around minimally processed plant foods. Dean Ornish, M.D., got up around there with his whole food, plant-based diet. It might not be as much as we were designed to eat, based on the analyses of fossilized feces, but that’s about where we might expect significantly lower stroke risk, as shown below and at 3:25 in my video. 

    How much were the UK vegetarians getting? 22.1 grams. Now, in the UK, they measure fiber a little differently, so it may be closer to 30 grams, but that’s still not the optimal level for stroke prevention. It’s so little fiber that the vegetarians and vegans only beat out the meat eaters by about one or two bowel movements a week, as you can see below and at 3:48 in my video, suggesting the non-meat eaters were eating lots of processed foods. 

    The vegetarians were only eating about half a serving more of fruits and vegetables. Intake is thought to reduce stroke risk in part because of their potassium content, but the UK vegetarians at higher stroke risk were eating so few greens and beans that they couldn’t even match the meat eaters. The vegetarians (and the meat eaters) weren’t even reaching the recommended minimum daily potassium intake of 4,700 mg a day.

    What about sodium? “The vast majority of the available evidence indicates that elevated salt intake is associated with higher stroke risk…” There is practically a straight-line increase in the risk of dying from a stroke, the more salt you eat, as you can see in the graph below and at 4:29 in my video. 

    Even just lowering sodium intake by a tiny fraction every year could prevent tens of thousands of fatal strokes. “Reducing Sodium Intake to Prevent Stroke: Time for Action, Not Hesitation” was the title of the paper, but the UK vegetarians and vegans appeared to be hesitating, as did the other dietary groups. “All groups exceeded the advised less than 2400 mg daily sodium intake”—and that didn’t even account for salt added to the table! The American Heart Association recommends less than 1,500 mg a day. So, they were all eating a lot of processed foods. It’s no wonder the vegetarians’ blood pressures were only one or two points lower. High blood pressure is perhaps “the single most important potentially modifiable risk factor for stroke.” 

    What evidence do I have that the vegetarians’ and vegans’ stroke risk would go down if they ate more healthfully? Well, in rural Africa, where they were able to nail the fiber intake that our bodies were designed to get by eating so many whole, healthy plant foods—including fruits, vegetables, grains, greens, beans, and protein almost entirely from plant sources—not only was heart disease, our number one killer, “almost non-existent,” but so was stroke. It only surged up from nowhere “with the introduction of salt and refined foods” to their diet. 

    “It is notable that stroke and senile dementia appear to be virtually absent in Kitava, an Oceanic culture [near Australia] whose quasi-vegan traditional diet is very low in salt and very rich in potassium.” They ate fish a few times a week, but the other 95 percent or so of their diet was made up of vegetables, fruits, corn, and beans. They had an apparent absence of stroke, even despite their ridiculously high rates of smoking, 76 percent of men and 80 percent of women. We evolved by eating as little as less than an eighth of a teaspoon of salt a day, and our daily potassium consumption is thought to have been as high as 10,000 mg or so. We went from an unsalted, whole-food diet to eating salty, processed foods depleted of potassium whether we eat meat or not. 

    Caldwell Esselstyn at the Cleveland Clinic tried putting about 200 patients with established cardiovascular disease on a whole food, plant-based diet. Of the 177 who stuck with the diet, only a single patient went on to have a stroke in the subsequent few years, compared to a hundred-fold greater rate of adverse events, including multiple strokes and deaths in those who strayed from the diet. “This is not vegetarianism,” Esselstyn explains. Vegetarians can eat a lot of less-than-ideal foods, “such as milk, cream, butter, cheese, ice cream, and eggs. This new paradigm is exclusively plant-based nutrition.” 

    This entire train of thought—that the reason typical vegetarians don’t have better stroke statistics is because they’re not eating particularly stellar diets—may explain why they don’t have significantly lower stroke rates. However, it still doesn’t explain why they may have higher stroke rates. Even if they’re eating similarly crappy, salty, processed diets, at least they aren’t eating meat, which we know increases stroke risk. There must be something about vegetarian diets that so increases stroke risk that it offsets their inherent advantages. We’ll continue our hunt for the answer next. 

    From a medical standpoint, labels like vegan and vegetarian just tell me what you don’t eat. It’s like identifying yourself as a “No-Twinkie-tarian.” You don’t eat Twinkies? Great, but what’s the rest of your diet like? 

    What are the healthiest foods? Check out my Daily Dozen.

    To catch up on the rest of this series, see related posts below. 

    Michael Greger M.D. FACLM

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  • What About Omega-3s and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Omega-3s and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    Does eating fish or taking fish oil supplements reduce stroke risk? 

    In my last video, we started to explore what might explain the higher stroke risk in vegetarians found in the EPIC-Oxford study. As you can see below and at 0:25 in my video Vegetarians and Stroke Risk Factors: Omega-3s?, vegetarians have a lower risk of heart disease and cardiovascular disease overall, but a higher risk of stroke. We looked into vitamin D levels as a potential mechanism, but that didn’t seem to be the reason. What about long-chain omega-3s, the fish fats like EPA and DHA? 

    Not surprisingly, their levels are found to be “markedly lower in vegetarians and particularly in vegans than in meat-eaters.” They’re about 30 percent lower in vegetarians and more than half as low in vegans, as you can see below and at 0:45 in my video. 

    According to “the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date,” combining 28 randomized controlled trials, stroke has no benefit. There is evidence that taking fish oil “does not reduce heart disease, stroke or death,” or overall mortality, either. This may be because, on the one hand, the omega-3s may be helping, but the mercury in fish may be making things worse. “Balancing the benefits with the contaminant risks of fish consumption has represented a challenge for regulatory agencies and public health professionals.”  

    For example, dietary exposure to polychlorinated biphenyls (PCBs) may be associated with an increased risk of stroke. In one study, for instance, “neither fish nor intake of PCBs was related to stroke risk. However, with adjustment for fish intake,” that is, at the same fish intake, “dietary PCBs were associated with an increased risk of total stroke,” so the PCB pollutants may be masking the fish benefit. If we had a time machine and could go back before the Industrial Revolution and find fish in an unpolluted state, we might find that it is protective against stroke. Still, looking at the EPIC-Oxford study data, if fish were protective, then we might expect that the pescatarians (those who eat fish but no other meat) would have lower numbers of strokes since they would have the fish benefit without the risk from other meat. But, no. That isn’t the reality. So, it doesn’t seem to be the omega-3s either.

    Let’s take a closer look at what the vegetarians are eating.

    When it comes to plant-based diets for cardiovascular disease prevention, all plant foods are not created equal. There are two types of vegetarians—those who do it for their health, and those who do it for ethical reasons, like global warming or animals—and the latter tend to eat different diets. Health vegans tend to eat more fruits and fewer sweets, for instance, and you don’t tend to see them chomping down on vegan donuts, as shown below and at 2:41 in my video. 

    “Concerns about health and costs were primary motivations for [meat] reduction” in the United States. A middle-class American family is four times more likely to reduce meat for health reasons compared to environmental or animal welfare concerns, as you can see in the graph below and at 2:55 in my video. 

    But in the United Kingdom, where the EPIC-Oxford stroke study was done, ethics was the number one reason given for becoming vegetarian or vegan, as you can see in below and at 3:05 in my video.

    We know that “plant-based diets, diets that emphasize higher intakes of plant foods and lower intakes of animal foods, are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all-cause mortality”—a lower risk of dying from all causes put together—“in a general US adult population.” But, that’s only for healthy plant foods. Eating a lot of Wonder Bread, soda, and apple pie isn’t going to do you any favors. “For all types of plant-based diets, however, it is crucial that the choice of plant foods is given careful consideration.” We should choose whole fruits and whole grains over refined grains and avoid trans fats and added sugars. Could it be that the veggie Brits were just eating more chips? We’ll find out next. 

    Another strikeout trying to explain the increased risk. Could it be that the vegetarians were eating particularly unhealthy diets? Labels like vegetarian or vegan just tell me what is not being eaten. You can be vegetarian and consume a lot of unhealthy fare, like french fries, potato chips, and soda. That’s why, as a physician, I prefer the term whole food, plant-based nutrition. That tells me what you do eat. You eat vegetables and follow a diet centered around the healthiest foods out there.

    If you missed the first four videos in this series, see:

     Surprised about the fishy oil findings? Learn more: Is Fish Oil Just Snake Oil? and Omega-3s and the Eskimo Fish Tale. 

    Michael Greger M.D. FACLM

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  • What About Vitamin D and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    What About Vitamin D and Vegetarians’ Stroke Risk?  | NutritionFacts.org

    Could the apparent increased stroke risk in vegetarians be reverse causation? And what about vegetarians versus vegans? 

    In the “Risks of Ischaemic Heart Disease and Stroke in Meat Eaters, Fish Eaters, and Vegetarians Over 18 Years of Follow-Up” EPIC-Oxford study, not surprisingly, vegetarian diets were associated with less heart disease—10 fewer cases per 1,000 people per decade compared to meat eaters—but vegetarian diets were associated with three more cases of stroke. So, eating vegetarian appears to lower the risk of cardiovascular disease by 7 overall, but why the extra stroke risk? Could it just be reverse causation?

    When studies have shown higher mortality among those who quit smoking compared to people who continue to smoke, for example, we suspect “reverse causality.” When we see a link between quitting smoking and dying, instead of quitting smoking leading to people dying, it’s more likely that being “affected by some life-threatening condition” led people to quit smoking. It’s the same reason why non-drinkers can appear to have more liver cirrhosis; their failing liver led them to stop drinking. This is the “sick-quitter effect,” and you can see it when people quit meat, too.

    As you can see below and at 1:16 in my video Vegetarians and Stroke Risk Factors: Vitamin D?

    , new vegetarians can appear to have more heart disease than non-vegetarians. Why might an older person all of a sudden start eating vegetarian? Well, they may have just been diagnosed with heart disease, so that may be why there appear to be higher rates for new vegetarians—an example of the sick-quitter effect. To control for that, you can throw out the first five years of data to make sure the diet has a chance to start working. And, indeed, when you do that, the true effect is clear: a significant drop in heart disease risk. 

    So, does that explain the apparent increased stroke risk, too? No, because researchers still found higher stroke risk even after the first five years of data were skipped. What’s going on? Let’s dive deeper into the data to look for clues.

    What happens when you break down the results by type of stroke and type of vegetarian (vegetarian versus vegan)? As you can see below and at 2:09 in my video, there are two main types of strokes—ischemic and hemorrhagic. Most common are ischemic, clotting strokes where an artery in the brain gets clogged off, as opposed to hemorrhagic, or bleeding strokes, where a blood vessel in the brain ruptures. In the United States, for example, it is about 90:10, with nine out of ten strokes the clotting (ischemic) type and one out of ten bleeding (hemorrhagic), the latter being the kind of stroke vegetarians appeared to have significantly more of. Now, statistically, the vegans didn’t have a significantly higher risk of any kind of stroke, but that’s terrible news for vegans. Do vegans have the same stroke risk as meat eaters? What is elevating their stroke risk so much that it’s offsetting all their natural advantages? The same could be said for vegetarians, too. 

    Even though this was the first study of vegetarian stroke incidence, there have been about half a dozen studies on stroke mortality. The various meta-analyses have consistently found significantly lower heart disease risk for vegetarians, but the lower stroke mortality was not statistically significant. Now, there is a new study that can give vegetarians some comfort in the fact that they at least don’t have a higher risk of dying from stroke, but that’s terrible news for vegetarians. Statistically, vegetarians have the same stroke death rate as meat eaters. Again, what’s going on? What is elevating their stroke risk so much that it’s offsetting all their natural advantages?

    Let’s run through a couple of possibilities. As you can see in the graph below and at 3:48 in my video, if you look at the vitamin D levels of vegetarians and vegans, they tend to run consistently lower than meat eaters, and lower vitamin D status is associated with an increased risk of stroke. But who has higher levels of the sunshine vitamin? Those who are running around outside and exercising, so maybe that’s why their stroke risk is better. What we need are randomized studies.

    When you look at people who have been effectively randomized at birth to genetically have lifelong, lower vitamin D levels, you do not see a clear indicator of increased stroke risk, so the link between vitamin D and stroke is probably not cause-and-effect.

    We’ll explore some other possibilities, next.

    So far in this series, we’ve looked at what to eat and what not to eat for stroke prevention, and whether vegetarians do have a higher stroke risk. 

    It may be worth reiterating that vegetarians do not have a higher risk of dying from a stroke, but they do appear to be at higher risk of having a stroke. How is that possible? Meat is a risk factor for stroke, so how could cutting out meat lead to more strokes? There must be something about eating plant-based that so increases stroke risk that it counterbalances the meat-free benefit. Might it be because plant-based eaters don’t eat fish? We turn to omega-3s next. For other videos in this series, see related posts below. 

    There certainly are benefits to vitamin D, though. Here is a sampling of videos where I explore the evidence.

    Michael Greger M.D. FACLM

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  • The 1 Heart-Health Habit You Should Start When You’re Young

    The 1 Heart-Health Habit You Should Start When You’re Young

    In your 20s and 30s, heart disease can seem like a far-off concern. It’s more common among people 75 or older than in any other age group.

    But there’s good reason to think about your heart health decades earlier: “While young adults often associate heart disease with people in their parents’ and grandparents’ ages, it’s never too early to start prevention,” says Dr. Nieca Goldberg, a cardiologist, author, and clinical associate professor at NYU Grossman School of Medicine. “In fact, 80% of heart disease is preventable.”

    If there’s just one thing you do for your heart when you’re young, it should be increasing your physical activity, experts agree. “Exercise is the foundation of heart-disease prevention, and combining aerobic exercise with resistance training has been shown to have the greatest impact on preventing and managing heart disease,” Goldberg says. That’s because physical activity taxes your heart and lungs, helping them to adapt to the stress and grow stronger over time.

    Getting regular exercise is also a step in the American Heart Association’s (AHA) Life’s Essential 8, a list of eight crucial health behaviors for maintaining optimal cardiovascular health. Aside from staying active, the list also includes eating a nutritious diet; managing your blood pressure, cholesterol, and blood sugar; maintaining a healthy weight; quitting tobacco; and getting plenty of sleep.

    Starting with physical activity will likely trickle down to these other arenas, says Dr. Keith Churchwell, president of the AHA. “If you stay active, it probably will help your sleep, it’ll probably help you in terms of thinking about your diet appropriately. It’ll help in terms of reducing your blood pressure, controlling your lipid status, your weight…and hopefully keep you away from other issues, like tobacco use.”

    How to get (even just a little) more exercise

    You don’t have to suddenly become a runner or join a gym if that’s not your style. You can focus on simply moving more throughout the day to start, Churchwell says. Take an extra stroll with your dog, meet a friend for a walk instead of a drink, finally give pickleball a try, or sign up for a dance class. Even just 20 more minutes of activity a day is a great benchmark to aim for, he says.

    It’s important not to go too hard, too fast. “The idea here is you want to establish lifestyle changes that are truly going to last you a lifetime,” says Dr. Nishant Shah, a preventive cardiologist and assistant professor at Duke University School of Medicine and the Duke Cardiometabolic Prevention Clinic. “Whatever you decide to do now, don’t do it with the intention of stopping it six months later.”

    Read More: How to Get Your Partner to Stop Snoring

    Establishing a lifelong fitness plan means identifying forms of exercise you actually like; it’s fine if CrossFit isn’t your thing. “Spend time to find activities that you enjoy so it doesn’t feel like a chore,” Goldberg says.

    Gradually build up to at least 150 minutes of moderate or 75 minutes of vigorous cardio activity, plus two strength-training sessions a week. That’s the general AHA recommendation for overall health and wellbeing. 

    You can modify and tailor your exercise program to your specific needs, abilities, interests, and fitness level, Goldberg says. If you’re not sure how to get started, speak with your doctor or a certified fitness professional who can guide you. “Start small and build from there: Consistency is key, so it’s important to ensure your routine is manageable based on your current lifestyle and commitments,” she says.

    It can get harder to start a physical activity routine as you get older, so it may be easier to maintain for your entire life if you make it a habit in your 20s or 30s. “When you maintain a habit of exercising at an earlier age, it’s just normal for you,” Shah says.

    Read More: How to Be More Spontaneous As a Busy Adult

    Finding the time can be tough, though, he admits. Try blocking off 30 to 60 minutes of your day for exercise just like you would for any other commitment or meeting, and then stick to it, he says.

    If you already exercise, keep building up your cardiovascular fitness and strength. There are even greater benefits of getting 300 (or more) minutes a week of physical activity.

    Shah offers one caveat to the exercise-first mentality: If you use tobacco, the most important heart-health habit for you, no matter your age, is to stop. While only about 5 to 12% of Americans in their 20s and 30s smoke now, according to a 2023 report in JAMA Health Forum, it’s still the most important habit to quit for your heart and overall health, he says, even before picking up an exercise routine. Smoking is linked to about one-third of heart disease-related deaths.

    And whether or not you’re ready to make some heart-healthy changes, talk with your relatives about any heart-health concerns in your family tree—especially your first-degree relatives. “Oftentimes when I see patients in this age range, they are unaware of any conditions that run in the family,” says Dr. Maxim Olivier, a cardiologist at Orlando Health Heart and Vascular Institute. “A good family history is very important to determine if they are at an increased risk for premature coronary artery disease, heart disease, or even sudden cardiac death. Though the ramifications may seem far off, there are patients who can present with heart disease as early as 20s to 30s, and even younger, which is often a reflection of their genetic predisposition and/or lifestyle.” 

    Sarah Klein

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  • The Stroke Risk of Vegetarians  | NutritionFacts.org

    The Stroke Risk of Vegetarians  | NutritionFacts.org

    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.

    Michael Greger M.D. FACLM

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

    Eating to Lower Lp(a)  | NutritionFacts.org

    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. 

    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

    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. 

    Michael Greger M.D. FACLM

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  • Should You Try to Raise Your ‘Good’ Cholesterol? You Might Not Need To

    Should You Try to Raise Your ‘Good’ Cholesterol? You Might Not Need To

    Most of the time, you want your cholesterol to be low—ideally less than 150 milligrams per deciliter (mg/dL). But as you likely know if you’ve had your levels tested, the results aren’t quite that simple.

    Cholesterol tests will tell you not just your total cholesterol, but also your low-density lipoprotein, triglycerides, and high-density lipoprotein. And you actually want your high-density lipoprotein, or HDL, to be high.

    HDL cholesterol is considered “good” cholesterol. While still a type of fat in your bloodstream, it doesn’t clog arteries, and higher levels are linked to lower chances of heart problems. Low-density lipoprotein, or LDL, is considered “bad” cholesterol because it’s the type that builds up in your arteries and can contribute to your risk for heart disease and stroke. Triglycerides, another type of fat in the blood, are tied to higher risks of heart attack and stroke if you also have low HDL or high LDL.

    It would make sense, then, that in order to protect your heart, you’d want to boost your good cholesterol, or HDL. But research examining increases in HDL so far hasn’t shown any subsequent reduction in heart problems, and medications that raise your good cholesterol don’t stave off those risks, either.

    Read More: How Stress Affects Your Heart Health

    “Starting from the 1970s, large population studies…showed that people who had very low levels of HDL cholesterol…had a higher risk of heart attacks,” says Dr. Anand Rohatgi, an academic cardiologist and professor of medicine in cardiology at UT Southwestern Medical Center. It’s a “powerful risk predictor,” he says, which is why low HDL made it into the heart disease risk calculators doctors still use today—but it doesn’t necessarily translate to a treatment tactic. Experts agree that the relationship between higher HDL levels and better heart health is correlational—not causative. “The challenge has been that when drugs have been studied that raise HDL cholesterol…that has never translated into a reduced risk for heart disease. So from a pharmaceutical standpoint, it’s not a treatment target—it’s a risk marker.” Instead of fixating on any one aspect of cholesterol, he says, you have to think of the numbers in concert, alongside other risk markers for heart problems like age, sex, blood pressure, and diabetes.

    That said, certain lifestyle habits do increase HDL, Rohatgi says; we just don’t necessarily know what effect raising your HDL cholesterol actually has on your heart. The numbers alone “are not a crystal ball.”

    The habits below are all associated with higher HDL levels—as well as other benefits for your heart and overall health.

    Exercise more

    A sedentary lifestyle is linked to a host of health problems, including a greater likelihood of heart disease. Moving more has routinely been shown to increase HDL levels, and it’s also linked to living longer and lower rates of heart disease.

    Aim for about 30 minutes a day, five days a week, says Dr. Melissa Tracy, cardiologist and medical director of cardiac rehabilitation at Rush University Medical Center. It can be any form of cardio exercise—brisk walking, pickleball, dancing, swimming, cycling, or anything else you enjoy and will stick with—as long as it gets your heart rate up. You can even do a few 10- or 15-minute sessions each day if that fits into your schedule better, she says.

    Eat heart-healthy unsaturated fats

    “Eating foods that are high in polyunsaturated and monounsaturated fats and antioxidants may improve the HDL to LDL ratio,” says Dr. Joy M. Gelbman, a cardiologist at Weill Cornell Medicine.

    Choose options like olive oil and fatty fish over foods higher in saturated fats like red meat, full-fat dairy, fried foods, and baked goods.

    Read More: Why Your Diet Needs More Fermented Pickles

    Making healthier diet choices overall means your body won’t store as much fat. You’ll be using your fat stores for some of your energy, which in turn helps your body metabolize cholesterol better, Tracy says. That may result in lower LDL and higher HDL, as HDL helps transport LDL to the liver where it’s processed and excreted, Rohatgi says.

    Quit smoking

    Smoking not only lowers your HDL; it also makes the HDL you do have worse at its protective job. Quitting smoking can increase your HDL in a matter of weeks, according to a meta-analysis in Biomarker Research.

    Experts don’t know exactly why this happens, but it might have to do with the way smoking stresses the body, Gelbman says.

    Shed excess weight

    “Exercise, weight loss in people [who are overweight], and smoking cessation are the key means for optimizing HDL,” Gelbman says. If you have obesity or are overweight, getting to a healthier weight may lower your triglycerides and LDL and lift your HDL.

    And the weight loss doesn’t have to be dramatic: People who lost just 1 to 3 percent of their body weight displayed better improvements in HDL than people who lost just 1% of their body weight in an Obesity Research & Clinical Practice study.

    Read More: No One Knows How to Talk About Weight Loss Anymore

    While finding a sustainable diet plan that helps you lose weight and keep it off is most important, research suggests eating more protein and fat and fewer carbs may have the biggest effect on HDL.

    Experts still don’t completely understand the concrete heart benefits of higher HDL levels. “It’s complex and dynamic, and that’s what makes it hard to study and hard to pin down,” Rohatgi says. But heart-healthy habits have additional benefits regardless of their effect on your cholesterol, such as greater longevity, improved cardiovascular fitness, and lower risk of heart disease. The fact that they also increase your HDL in the process is an added perk.

    Sarah Klein

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  • One Positive Sleep Habit Can Be Doubly Good

    One Positive Sleep Habit Can Be Doubly Good

    Millions struggle with not being able to sleep.  There are a few things you do to help with your sleep habits – and this one could have a double positive impact.

    Snuggling in bed and falling into a deep sleep is so satisfying. Nothing like waking up and feeling great…but for millions it is sometimes a nightmare. Almost 40% of adults not getting enough sleep and some  55 to 75 million Canadians and Americans have  ongoing, sleep disorders. But this one positive sleep habit  can be doubly good for you.

    Routines are key to sleep for most people. Science says the body operates better on a schedule. So deviling habits around sleep can lead to a more successful result.  Lack of sleep can not only cause including poor concentration, reduced reaction times and altered mood, but also heart issues.

    RELATED: Sleeping Less Than 5 Hours A Night May Increase Your Risk Of This

    A study reported in the  European Heart Journal—Digital Health, anaylized over 88,000 adults for a period of six years, trying to get an understanding of the relationship between sleep and heart health. Researchers were able to access information about the subject’s lifestyle, demographics, physical activity, and health.

    After accounting for a variety of factors like lifestyle, stress, gender, and more, the study found that there was a 12% increase in heart disease amongst people who went to bed between the hours of 11 and 11:59 PM. This percentage increased to 25% when people went to bed past midnight. Women seemed to be affected more by these times when compared to men, experiencing higher risks.

    Study co-author David Plans explained in a statement how circadian rhythms worked and why our bedtime could play an important part in our heart health. “While we cannot conclude causation from our study, the results suggest that early or late bedtimes may be more likely to disrupt the body clock, with adverse consequences for cardiovascular health,” he said.

    Sleeping Too Little May Increase This Group's Risk Of Dementia
    Photo by Bruno Aguirre via Unsplash

    RELATED: 3 Tricks That Can Help You Understand Your Sleep

    Heart disease is the leading cause of death for most people in America, thus a prominent concern for most of us. It’s influenced by internal factors like cholesterol levels and blood pressure, but also by outside forces, like smoking, and, apparently, your sleep habits.

    While the results are not conclusive and don’t suggest sleeping in earlier you’ll be cutting your risk of heart disease, they do imply that there’s a connection between good sleep and heart health.

    Amy Hansen

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  • The Truth About Heart Stents | NutritionFacts.org

    The Truth About Heart Stents | NutritionFacts.org

    Coronary artery disease, the number one killer of men and women, involves blockages in the blood vessels that supply the heart muscle. As discussed in my video Do Angioplasty Heart Stent Procedures Work?, low blood flow can lead to a type of chest pain called angina or, if severe enough, a heart attack. Plant-based diets and lifestyle programs have been shown to help reverse these blockages by treating the cause of why our arteries are clogging up in the first place. But, for those unable or unwilling to change their diets, there are drugs that may help, as well as more invasive surgical treatments.

    What Is a Heart Stent?

    You may have heard of open-heart surgery, performed to try to bypass the blockage, or percutaneous coronary intervention. As discussed in my video Why Angioplasty Heart Stents Don’t Work Better, historically, the more common procedure was angioplasty, wherein a tiny balloon is inserted into a narrowed coronary artery feeding your heart to force it to open wider to improve blood flow. Then, stents came into vogue. Instead of just ballooning up the artery, how about permanently inserting a metal mesh tube to prop open the artery? Stents are typically inserted in the groin and threaded all the way up into the heart, and, while stents used to be mostly bare metal, there are now fancy new drug-eluting stents that not only force open arteries, but they also slowly release pharmaceuticals.

    How Serious Is Having a Stent Put In?

    The surgical procedure carries risks—including death. In an emergency setting, while you’re actively having a heart attack, angioplasty can be lifesaving, but hundreds of thousands of these procedures are for stable coronary artery disease, for which there appears to be little or no benefits. As discussed in my video The Risks of Heart Stents, doctors appear to be killing or stroking out thousands of people a year for nothing, and that isn’t even counting the tens of thousands of silent mini-strokes caused by these procedures that may contribute to cognitive decline. Indeed, 11 to 17 percent of people who go through angioplasty or stenting come away with new brain lesions—up to one in six patients.

    Do Stents Work?

    Angioplasty and stents for non-emergency coronary artery disease are among the most common invasive procedures performed in the United States. Millions of people have gotten stents for stable coronary artery disease, yet it now appears that for such patients, angioplasty and stent placement do not actually prevent heart attacks, do not offer long-term angina pain relief, and do not improve survival. Why? Because the most dangerous plaques—the ones most vulnerable to rupture leading to a heart attack—are not the ones doctors put stents into. They often aren’t the ones that are even seen on angiogram to be obstructing blood flow.

    Indeed, in 2007, we learned from the COURAGE trial that angioplasty and stents don’t reduce the risk of death or heart attack, but patients didn’t seem to get the memo. As discussed in my video Why Are Stents Still Used If They Don’t Work?, only 1 percent realize there was no mortality or heart attack benefit, perhaps because most cardiologists failed to happen to mention that fact. One can imagine that if patients actually understood all they were getting was symptomatic relief, they’d be less likely to go under the knife. Ten years later, the ORBITA trial was published, showing even the promise of symptom relief was an illusion.

    Are Stents Really Necessary?

    The implications are profound and far-reaching. First and foremost, the results showed unequivocally that there are no benefits to non-emergency angioplasty and stents for stable heart disease. Basically, patients would be risking harm for no benefit whatsoever, so it’s hard to imagine a scenario where a fully-informed patient would choose an invasive procedure for nothing.

    Yet angioplasty and stent placement continue to be frequently performed for patients with non-emergency coronary artery disease, despite clear evidence that it provides minimal benefit, as discussed in my video Angioplasty Heart Stent Risks vs. Benefits. For example, it does not prevent heart attacks or death, yet as many as nine out of ten patients mistakenly believed that the procedure would reduce their chances of having a heart attack.

    What Are the Side Effects of Heart Stents?

    Stent placement and the blood-thinner drugs you have to go on after the surgery can cause complications, including heart failure, stroke, and death. The risks are relatively low; there’s less than a 1 percent chance it will kill you or stroke you out. The 15 percent risk of heart attack is only if your stent clogs at a later date, which only happens about 1 percent of the time in the near-term. There is a 13 percent risk of kidney injury, due to the dyes that must be injected, but that typically heals on its own. The most serious complications—including death—only happen in about 1 in 150 cases. However, you have to multiply that by the fact that hundreds of thousands of these procedures are performed every year.

    And, again, although stents appeared to offer immediate relief of angina chest pain in stable patients with coronary artery disease, they do not offer long-term angina pain relief and they didn’t actually translate into lower risk of heart attack or death. More on this in my video Do Heart Stent Procedures Work for Angina Chest Pain?.

    Diet After Heart Attack and Stents

    Should we be surprised that angioplasty and stents fail to improve prognosis? After all, neither does anything to modify the underlying disease process itself. In other words, they don’t treat the cause. As discussed in my video Heart Stents and Upcoding: How Cardiologists Game the System, even if stents helped with symptoms beyond the placebo effect, they would still just be treating the symptoms, not the disease, so it’s no wonder the disease continues to progress until the patient is disabled into death.

    Thankfully, we are on the cusp of a seismic revolution in health: not another pill, procedure, or operation, but, instead, treating the underlying cause of heart disease with whole food, plant-based nutrition, the mightiest tool medicine has ever had in its toolbox.

    Heart-Healthy Eating

    The most likely reason the majority of our loved ones will die is heart disease. Atherosclerosis, or hardening of the arteries, begins in childhood, as discussed in my video How Not to Die from Heart Disease. The arteries of nearly all kids raised on the standard American diet already have fatty streaks marking the first stage of the disease—by the time they are ten years old. After that, the plaques start forming in our 20s, get worse in our 30s, and can then start killing us off. In our heart, it’s called a heart attack; in our brain, it can manifest as a stroke. So, for anyone reading this who is older than ten, the choice isn’t whether or not to eat healthfully to prevent heart disease—it’s whether or not you want to reverse the heart disease you likely already have.

    Is that even possible? When researchers took people with heart disease and put them on the kind of plant-based diet followed by populations who did not get epidemic heart disease, their hope was that it might slow down the disease process or maybe even stop it. Instead, something miraculous happened. The disease actually started to reverse. It started to get better. As soon as patients stopped eating artery-clogging diets, their bodies were able to start dissolving away some of the plaque, opening up arteries without drugs and without surgery, suggesting their bodies wanted to heal all along, but just were never given the chance. That improvement in blood flow to the heart muscle itself was after just three weeks of eating healthfully.

    Plant-based diets aren’t just safer and cheaper. They can work better because they let us treat the actual cause of the disease.

    Michael Greger M.D. FACLM

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  • How to Talk to Your Family About Their Heart Health History

    How to Talk to Your Family About Their Heart Health History

    Hypertrophic obstructive cardiomyopathy (HOCM) is the most common genetic heart disease, affecting about 1 in every 500 people, according to the American Heart Association (AHA). In people with HOCM, genetic variants cause the heart’s walls to thicken and stiffen, blocking blood from flowing freely from the left ventricle to the aorta. This, in turn, results in shortness of breath and chest pain (especially during physical activity), abnormal heart rhythms, lightheadedness, dizziness, and fainting, and can worsen over time.

    If a parent has HOCM, offspring have a 50% chance of inheriting it. That means knowing your family’s heart health history is crucial: If your doctor is aware that you have relatives with HOCM, they can “screen family members early on, before they get sick or have any cardiac complications” using EKG and echocardiogram, says Dr. Ali Nsair, co-director of the Hypertrophic Cardiomyopathy Clinic at UCLA Health.

    About 60% of the time, genetic testing can identify a specific change in a gene that causes HOCM. Even if you (or your kids) test negative for the particular genetic variant your parent with HOCM has, you can still be screened every few years with EKGs, echocardiograms, and visits to a cardiologist to make sure complications haven’t popped up, Nsair says.

    And it’s not only HOCM that can cluster in families. “A lot of what ails us is in some sense heritable,” says Dr. Daniele Massera, associate director of the Hypertrophic Cardiomyopathy Program at NYU Langone Health. “Whatever affects your family members might directly affect you.” Other heart conditions, like familial hypercholesterolemia (high cholesterol) and high lipoprotein (a) (proteins and fats that carry cholesterol), can be inherited, and a family history of heart disease that isn’t genetic puts you at higher risk, too.

    But no single risk factor—including genetics—is a guarantee that heart disease will develop down the line: “For me, the most important reason to know your family history is prevention,” says Dr. Svati Shah, a member of the American Heart Association’s National Board of Directors and director of the Duke Adult Cardiovascular Genetics Clinic. If you know you have an increased risk for heart disease due to your genes or family history, which you can’t control, you can take heart-healthy steps to improve the lifestyle factors you can control, such as getting plenty of sleep, eating a balanced diet, and staying active, according to the AHA.

    To make sure you get access to the testing, treatment, and information on lifestyle changes that can help you avoid or delay inherited heart health complications, it’s important to stay on top of your family’s medical history. Here’s how to have those conversations with honesty and compassion while still getting the potentially life-saving answers you need.

    Read More: What It Means if You Have Borderline High Cholesterol—And What to Do About It

    Start with broad questions

    You might open the conversation with a question as simple as “Do you have any kind of heart disease?” or as general as: “Have you ever had any chest pain?” Shah suggests.

    If your relative isn’t entirely sure about their diagnosis or past procedures, consider asking if a doctor has ever told them they had any of the following, according to the Centers for Disease Control and Prevention (CDC):

    • Coronary artery disease or atherosclerosis
    • Heart attack
    • Arrhythmia
    • Atrial fibrillation
    • Cardiomyopathy
    • Heart failure
    • Aortic aneurysm
    • Stroke

    Also ask if they have a pacemaker or have ever had heart bypass surgery. If they’ve given birth, Shah suggests adding: “Did anything happen [to your heart] when you had your babies? Did you get really high blood pressure?” And whenever possible, ask what age they were when they experienced these conditions or complications for the first time, according to the CDC.

    The details might get fuzzier as you go back generations. “Often people say [things like], ‘My dad died at 47 from a heart attack,’ but it’s actually that they didn’t wake up from sleep, and it may not have been a heart attack,” Massera says.

    Try to get as many details as you can, because those specifics can help your doctor determine the best next steps for you. For example, you might need different testing if your 47-year-old father died of sudden cardiac arrest (when the heart suddenly stops beating) rather than a heart attack (when an artery to the heart is blocked). “To distinguish between the two is really critical: A heart attack is common, but if we identify sudden cardiac death as the real mechanism, then we’re homing in on a more narrow group of conditions that will require testing that you wouldn’t necessarily do if you’re talking about a heart attack,” Massera says.

    While heart attacks, strokes, and sudden cardiac death might stand out the most in your relatives’ memories, make sure to ask about heart disease risk factors too, like high blood pressure, high cholesterol, and diabetes. “There is a strong predictor among those factors that can lead to heart disease and heart failure,” Massera says.

    Talk to three generations on both sides of your family

    Ideally, aim to include three generations on both sides of your family in your discussions about heart health: your grandparents, your parents and their siblings, and your siblings.

    “Backwards more than three generations, people don’t really know what happened to those relatives,” Shah says. But any information you can collect is still better than nothing, especially if you continue to gather knowledge over time. “[Learn] as much as you can, and it can be over the course of many years that you fill in the details,” she says.

    If you or your siblings have children, note any known heart health information about them, too, per the CDC.

    Be gentle

    These discussions may not go as well if your brother feels interrogated or your mother feels blamed. “These can be really laden conversations,” Shah says. “Especially when you start talking about weight, high cholesterol, blood pressure—people can get sensitive about that.”

    If a family member remains standoffish, don’t press: “If that person isn’t ready, it’s OK, circle back to it,” Shah says. Your relatives might feel more comfortable in a group setting. “Sometimes one on one, people ask: ‘Why are you calling me? Why are you worried about my health? Why aren’t you worried about other people’s health?’” Group conversations have the added benefit of helping to nudge everyone’s memory in the right direction, too. “Sometimes one person remembers one thing, another person remembers another thing, but if you spoke with each one independently, you wouldn’t have made the connection,” Shah says.

    These conversations don’t have to be done in person, but face-to-face discussions allow you to pick up on a relative’s body language more easily and change the subject if you can tell they’re uncomfortable.

    Record the information somewhere you can access it easily

    You can use digital tools like the Surgeon General’s My Family Health Portrait or the Global Alliance for Genomics and Health’s Family History Toolkit to record and store your family’s heart health history.

    Don’t feel pressured to use software: Typing notes into your smartphone or jotting them down on paper is fine, too. As long as it’s a system that works for you and you know where the information is, you’ll be less likely to forget any details when you’re actually sitting in front of your doctor.

    “I love it when patients come in with a printout,” Massera says. He makes sure to devote plenty of time to walk through all of a patient’s relatives and their relevant health history, but recognizes a typical primary care doctor might not have that luxury. “You can’t do this if you see a patient in five minutes,” he says. If you feel like your doctor isn’t giving you enough time to cover your family history thoroughly, it’s OK to ask for a longer appointment to address your concerns, he adds.

    Read More: How Stress Affects Your Heart Health

    Report back to your doctor

    Simply knowing your family’s heart health history isn’t enough to prevent your own heart issues. Sharing what you’ve learned with your doctor is key to determining the screenings, treatment, or lifestyle changes that might benefit you.

    To that end, share “broadly” with your primary care doctor once you’ve asked your family about their heart health, Nsair says. Your doctor will dig deeper into the information that’s most relevant to your individual health, but it’s always better to provide too much than too little.

    A history of heart failure, heart rhythm disorders, stroke, and sudden death, especially in relatives younger than 40 or 50, will likely prompt your primary care doctor to refer you to a cardiologist. That person or your primary care doctor can help you identify modifiable risk factors that you can change, such as quitting smoking, adopting a balanced diet, starting an exercise routine, and maintaining a healthy weight.

    You won’t have to do this every time you visit the doctor: Once you’ve shared your family heart health history, that information is entered into your medical records, so anyone who is a part of your care team will have access to the same details.

    Chat again whenever big changes occur

    Your family’s heart health will continue to change over time—after all, many heart issues, including HOCM, are more common in middle age—so it’s hard to say exactly how often to ask your relatives about their heart health.

    In general, it’s a good idea to collect more information whenever a family member experiences a major heart-related health issue, like a sudden death, cardiac arrest, or having a defibrillator implanted. “This is not a conversation you need to have every year. But every few years, reassess,” Shah advises.

    Remember, these conversations may be challenging, but they’re empowering you with the information you need to live well for longer. “Genetics is not destiny. There’s a saying that genetics loads the gun, but the environment pulls the trigger,” Shah says. “You have control over this.”

    Sarah Klein

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