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Tag: hypertension

  • Keeping Better Score of Your Diet | NutritionFacts.org

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    How can you get a perfect diet score?

    How do you rate the quality of people’s diets? Well, “what could be more nutrient-dense than a vegetarian diet?” Indeed, if you compare the quality of vegetarian diets with non-vegetarian diets, the more plant-based diets do tend to win out, and the higher diet quality in vegetarian diets may help explain greater improvements in health outcomes. However, vegetarians appear to have a higher intake of refined grains, eating more foods like white rice and white bread that have been stripped of much of their nutrition. So, just because you’re eating a vegetarian diet doesn’t mean you’re necessarily eating as healthfully as possible.

    Those familiar with the science know the primary health importance of eating whole plant foods. So, how about a scoring system that simply adds up how many cups of fruits, vegetables, whole grains, beans, chickpeas, split peas, and lentils, and how many ounces of nuts and seeds per 1,000 calories (with or without counting white potatoes)? Looking only at the total intake of whole plant foods doesn’t mean you aren’t also stuffing donuts into your mouth. So, you could imagine proportional intake measures, based on calories or weight, to determine the proportion of your diet that’s whole plant foods. In that case, you’d get docked points if you eat things like animal-derived foods—meat, dairy, or eggs—or added sugars and fats.

    My favorite proportional intake measure is McCarty’s “phytochemical index,” which I’ve profiled previously. I love it because of its sheer simplicity, “defined as the percent of dietary calories derived from foods rich in phytochemicals.” It assigns a score from 0 to 100, based on the percentage of your calories that are derived from foods rich in phytochemicals, which are biologically active substances naturally found in plants that may be contributing to many of the health benefits obtained from eating whole plant foods. “Monitoring phytochemical intake in the clinical setting could have great utility” in helping people optimize their diet for optimal health and disease prevention. However, quantifying phytochemicals in foods or tissue samples is impractical, laborious, and expensive. But this concept of a phytochemical index score could be a simple alternative method to monitor phytochemical intake.

    Theoretically, a whole food, plant-based or vegan diet that excluded refined grains, white potatoes, hard liquors, added oils, and added sugars could achieve a perfect score of 100. Lamentably, most Americans’ diets today might be lucky to score just 20. What’s going on? In 1998, our shopping baskets were filled with about 20% whole plant foods; more recently, that has actually shrunk, as you can see below and at 2:49 in my video Plant-Based Eating Score Put to the Test.

    Wouldn’t it be interesting if researchers used this phytochemical index to try to correlate it with health outcomes? That’s exactly what they did. We know that studies have demonstrated that vegetarian diets have a protective association with weight and body mass index. For instance, a meta-analysis of five dozen studies has shown that vegetarians had significantly lower weight and BMI compared with non-vegetarians. And even more studies show that high intakes of fruits, vegetables, whole grains, and legumes may be protective regardless of meat consumption. So, researchers wanted to use an index that gave points for whole plant foods. They used the phytochemical index and, as you may recall from an earlier video, tracked people’s weight over a few years, using a scale of 0 to 100 to simply reflect what percentage of a person’s diet is whole plant foods. And even though the healthiest-eating tier only averaged a score of about 40, which meant the bulk of their diet was still made up of processed foods and animal products, just making whole plant foods a substantial portion of the diet may help prevent weight gain and decrease body fat. So, it’s not all or nothing. Any steps we can take to increase our whole plant food intake may be beneficial.

    Many more studies have since been performed, with most pointing in the same direction for a variety of health outcomes—indicating, for instance, higher healthy plant intake is associated with about a third of the odds of abdominal obesity and significantly lower odds of high triglycerides. So, the index may be “a useful dietary target for weight loss,” where there is less focus on calorie intake and more on increasing consumption of these high-nutrient, lower-calorie foods over time. Other studies also suggest the same is true for childhood obesity.

    Even at the same weight, with the same amount of belly fat, those eating plant-based diets tend to have higher insulin sensitivity, meaning the insulin they make works better in their body, perhaps thanks to the compounds in plants that alleviate inflammation and quench free radicals. Indeed, the odds of hyperinsulinemia—an indicator of insulin resistance—were progressively lower with greater plant consumption. No wonder researchers found 91% lower odds of prediabetes for people getting more than half their calories from healthy plant foods.

    They also found significantly lower odds of metabolic syndrome and high blood pressure. There were only about half the odds of being diagnosed with hypertension over a three-year period among those eating more healthy plants. Even mental health may be impacted—about 80% less depression, 2/3 less anxiety, and 70% less psychological distress, as you can see below and at 5:15 in my video.

    Is there a link between the dietary phytochemical index and benign breast diseases, such as fibrocystic diseases, fatty necrosis, ductal ectasia, and all sorts of benign tumors? Yes—70% lower odds were observed in those with the highest scores. But what about breast cancer? A higher intake of healthy plant foods was indeed associated with a lower risk of breast cancer, even after controlling for a long list of other factors. And not just by a little bit. Eating twice the proportion of plants compared to the standard American diet was linked to more than 90% lower odds of breast cancer.

    Doctor’s Note

    You can learn more about the phytochemical index in Calculate Your Healthy Eating Score.

    If you’re worried about protein, check out Flashback Friday: Do Vegetarians Get Enough Protein?

    It doesn’t have to be all or nothing, though. Do Flexitarians Live Longer?

    For more on plant-based junk, check out Friday Favorites: Is Vegan Food Always Healthy?.

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    Michael Greger M.D. FACLM

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  • How to turn on hypertension alerts on Apple Watch

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    Apple has steadily expanded the Apple Watch’s health monitoring features over the years, moving beyond fitness tracking into areas that can offer early insight into potential medical concerns. One of the most recent additions is hypertension alerts, which are designed to notify users when their blood pressure trends are elevated over time. While Apple Watches cannot directly measure blood pressure, this feature can still play a useful role in highlighting patterns that may be worth discussing with your doctor. Here, we’ll explain what hypertension alerts do, how they work and how to enable and manage them on the Apple Watch.

    What hypertension alerts do

    Hypertension alerts are designed to identify long-term trends that may indicate elevated blood pressure. Instead of relying on a traditional cuff measurement, the Apple Watch analyzes a combination of health data collected over a 30-day period, including heart rate, movement patterns and other contextual information stored in the Health app. Using this data, the system looks for sustained changes that align with patterns commonly associated with hypertension.

    If your Apple Watch detects a trend suggesting elevated blood pressure over an extended period, it’ll send you a notification. These alerts are not intended to diagnose hypertension or replace medical testing. Instead, they serve as an early signal that something may have changed and that you may want to seek further monitoring or professional advice.

    Apple emphasizes that hypertension alerts are designed for users who have not already been diagnosed with high blood pressure. Instead, they are meant to raise awareness rather than confirm a condition.

    Who can use hypertension alerts

    Hypertension alerts require a compatible Apple Watch model (Apple Watch Series 9 or later, or Apple Watch Ultra 2 or later) paired with a supported iPhone (iPhone 11 or later). The feature also depends on recent versions of watchOS and iOS, as it relies on updated health algorithms and background data analysis. To use hypertension alerts you must be 22 years of age or older, not be pregnant and not have been diagnosed with hypertension. You also need to ensure that your Apple Watch’s Wrist Detection feature is turned on.

    To receive meaningful alerts, your Apple Watch needs sufficient data. This means wearing the watch regularly, including during sleep if sleep tracking is enabled, and keeping health details such as age, sex, height and weight up-to-date in the Health app. The system uses long-term trends, so alerts will not appear immediately after enabling the feature.

    How to turn on hypertension alerts

    Hypertension alerts are managed through the Health app on the paired iPhone. The feature cannot be enabled directly from the watch itself. During setup, the Health app will ask for confirmation that the user has not been diagnosed with hypertension. It may also prompt a review of health details such as date of birth and biological sex, as this information helps improve the accuracy of trend analysis.

    To get started, open the Health app on the iPhone paired with the Apple Watch. From the main Health screen, tap your profile in the top corner. Select Health Checklist from the available Features. Next, you’ll need to tap Hypertension Notifications, confirm your age and whether or not you’ve ever been diagnosed with hypertension. Tap Continue and follow the on-screen prompts for information on how the notifications work. Once you have done this, tap Done and you’ll be all set.

    Once enabled, the feature runs automatically in the background. There is no need to manually start monitoring or interact with the feature daily.

    The new apple watch series 11 can help identify hypertension (Apple)

    Managing notifications and alerts

    When hypertension alerts are turned on, notifications appear on both the Apple Watch and the paired iPhone. These alerts typically explain that a long-term trend suggesting elevated blood pressure has been detected, along with guidance on next steps.

    Users can manage how and when these notifications appear by adjusting notification settings for the Health app. This includes choosing whether alerts appear on the lock screen, in Notification Center or as time-sensitive notifications on Apple Watch.

    Health data related to hypertension alerts can be reviewed at any time in the Health app. While Apple Watch does not display a specific blood pressure number, users can view contextual information and educational material explaining what the alert means and what actions may be appropriate.

    How hypertension alerts can help

    Hypertension often develops gradually and may not cause noticeable symptoms in its early stages. Because of this, many people are unaware of elevated blood pressure until it is identified during a routine medical check.

    Hypertension alerts can let you know of subtle changes that might have otherwise gone unnoticed. For some users, an alert may prompt earlier conversations with a doctor, additional blood pressure monitoring at home or lifestyle changes such as adjustments to diet, activity or sleep habits.

    It is important to treat these notifications as informational rather than diagnostic. Apple Watch does not provide specific blood pressure readings and cannot confirm hypertension on its own.

    What to do if you receive an alert

    Receiving a hypertension alert does not mean that there is an immediate medical emergency. Apple recommends using the alert as a prompt to pay closer attention to your cardiovascular health.

    Many users choose to follow up by measuring blood pressure using a traditional cuff at home or by scheduling a check with a healthcare professional. A doctor can provide proper testing, diagnosis and guidance based on clinical measurements and individual risk factors.

    It is also worth reviewing lifestyle factors that can influence blood pressure, such as physical activity levels, sleep quality, stress and diet. Apple Watch can already help track many of these areas, which may provide useful context when discussing health concerns with a professional.

    Limitations to keep in mind

    Hypertension alerts are not available in all regions and may be subject to regulatory approval. The feature also requires consistent Apple Watch use over time to generate reliable trend data.

    Most importantly, the Apple Watch does not measure blood pressure directly. The alerts are based on correlations and trends rather than direct readings, which means they should not be used as a substitute for medical equipment or professional care.

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    Rob Webb

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  • Brain Health Challenge: Doctor Appointments for Your Mind and Body

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    Congratulations, you’ve reached the final day of the Brain Health Challenge! Today, we’re asking you to do a few things that might feel a bit out of left field — like getting your blood pressure checked.

    No, it isn’t as fun as playing Pips, but experts say it’s one of the most important things you can do for your brain. That’s because heart health and brain health are intrinsically linked.

    High blood pressure, in particular, can damage brain cells, and it’s a significant risk factor for stroke and dementia. When blood pressure is too high, it places stress on the walls of arteries in the brain. Over time, that added stress can cause the blood vessel walls to thicken, obstructing blood flow. In other cases, the increased pressure causes the artery walls to thin and leak blood into the brain.

    These changes to the blood vessels can sometimes cause a large stroke to occur. More commonly, the damage leads to micro-strokes and micro-hemorrhages, which cause fewer immediate problems and often go unnoticed. But if someone has hypertension for years or decades, these injuries can build up, and the person may start to experience cognitive impairment.

    High blood pressure “is known as a silent killer for lots of reasons,” said Dr. Shyam Prabhakaran, the chair of neurology at the University of Chicago. “It doesn’t cause you any symptoms until it does.”

    Because the damage accumulates over many years, experts say that managing blood pressure in midlife matters most for brain health. Hypertension can be addressed with medication or lifestyle changes, as directed by your doctor. But the first thing you need to do is know your numbers. If your blood pressure comes back higher than 120/80, it’s important to take it seriously, Dr. Prabhakaran said.

    While you’re at it, there are a few other aspects of your physical health that you should check on.

    Your eyes and ears are two of them. Hearing and vision loss have both been shown to increase the risk of dementia. Experts think that with less sensory information coming in to stimulate the brain, the regions that process hearing and vision can start to atrophy. What’s more, people with sensory loss often withdraw or are left out of social interactions, further depriving them of cognitive stimulation.

    Oral health can also affect your brain health. Research has found a connection between regular flossing and reduced odds of having a stroke. That may be because good oral health can help to reduce inflammation in the body. The bacteria that cause gum disease have also been tied to an increased risk of Alzheimer’s.

    And have you gotten your shingles vaccine? There is mounting evidence that it’s a powerful weapon for protecting against dementia. One study found that it lowered people’s odds of developing the condition by as much as 20 percent.

    To wrap up this challenge, we want you to schedule a few medical appointments that benefit your brain, as well as your body.

    After five days of feeding, exercising and challenging your brain, you are well on your way to better cognitive health. Thanks for joining me this week, and keep up the good habits!

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    Dana G. Smith

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  • To find living donors for kidney transplants, a pilot program turns to social networks

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    HARRISBURG, Pa. — Fernando Moreno has been on dialysis for about two years, enduring an “unbearable” wait for a new kidney to save his life. His limited world of social contacts has meant that his hopes have hinged on inching up the national waiting list for a transplant.

    That was until earlier this year, when the Philadelphia hospital where he receives treatment connected him with a promising pilot project that has paired him with “angel advocates” — Good Samaritan strangers scattered around the country who leverage their own social media contacts to share his story.

    So far, the Great Social Experiment, as it was named by its founder, Los Angeles filmmaker David Krissman, hasn’t found the Vineland, New Jersey, truck driver a living kidney donor. But there are encouraging early signs the angel advocate approach is working, and there’s no question it has given Moreno new optimism.

    “This process is great,” said Moreno, 50, whose own father died of kidney failure at 65. “I’m just hoping there will be somebody out there that’s willing to take a chance.”

    Moreno is part of a pilot program with 15 patients that began in May at three Pennsylvania hospitals. It’s testing whether motivated, volunteer strangers can help improve the chances of finding a life-saving match for a new kidney — particularly for people with limited social networks.

    “We know how this has always been done, and we’re trying to put that on steroids and really get them the help that they need,” Krissman said. “Most patients are too sick to do this on their own — many don’t have the skills to do it on their own.”

    The Gift of Life Donor Program, which serves as the organ procurement network for eastern Pennsylvania, southern New Jersey and Delaware, is supporting the pilot program with a grant of more than $100,000 from its foundation.

    So far, two of the five patients in the program through Temple University Hospital have found kidney donors, and one is preparing for surgery, according to Ryan Ihlenfeldt, the hospital’s director of clinical transplant services. One of the five patients at the University of Pittsburgh Medical Center in Harrisburg has also undergone a transplant.

    The approach Krissman has developed is something new, said Richard Hasz Jr., Gift of Life’s chief executive, and may help identify the types of messages that attract and motivate potential live kidney donors.

    “This is the first of its kind that I’m aware of,” Hasz said. “That’s why, I think, the foundation was so interested in doing it — studying it and hopefully publishing it — so we can create that blueprint, if you will, for the future.”

    Gift of Life agreed to fund a broader test and helped Krissman identify five patients each at Temple, UPMC-Harrisburg and Jefferson University Hospital in Philadelphia.

    Hasz said the pilot program’s approach combines social media outreach with Krissman’s storytelling talents and aggressive efforts to mobilize the patients’ own connections.

    “We know that patients who are waiting don’t always have the energy or the resources to do this themselves,” Hasz said.

    There have been other ways for patients to set up “ microsites ” where they can tell their stories and seek a donor match. But the pilot program currently underway in Pennsylvania aims to connect patients with a wide universe of potential donors and produce videos and other ways to spread their message.

    Krissman’s bout with an illness about two decades ago inspired him to tackle the sticky challenge of increasing live kidney donations. He was debilitated for more than a year before medication helped him recover, explaining, “It gave me my life back. And I never forgot what it’s like to be chronically sick.”

    After producing a podcast on kidney transplantation, Krissman recruited four patients through Facebook who were waiting for kidneys. He was able to help two of them. A second effort, a pilot program with three patients in North Carolina that ended last year, helped match all three with living donors.

    Becca Brown, director of transplant services at UPMC-Harrisburg, thinks it might be a game changer.

    “There’s potential for this to really snowball,” Brown said. “I’m anxious to see what happens and if we can roll it out to other patients.”

    Some 90,000 people in the United States are on a list for a kidney transplant, and most of the roughly 28,000 kidneys that were transplanted last year came from deceased donors. Living kidney donations are hard to come by — about 6,400 were transplanted last year. Thousands die each year waiting for an organ transplant in the United States.

    Living kidney donations can be a better match, reducing the risk of organ rejection. They allow for surgery to be planned for a time that is optimal for the donor, the recipient and the transplant team. And, the foundation says, living donor kidneys, on average, last longer than kidneys from deceased donors.

    The National Kidney Foundation says living donors must be at least 18 years old, although some transplant centers set the minimum age at 21. Potential donors get screened for health problems and can be ruled out if they have uncontrolled high blood pressure, diabetes or cancer, or if they are smokers.

    Many living donors make “directed donations” to specify who will get their kidney. Nondirected donations are made anonymously to a patient.

    Francis Beaumier, a 38-year-old information technology worker from Green Bay, Wisconsin, came into contact with the angel advocate program after being a double living donor — a kidney and part of his liver.

    He sees the program as “a great little way for everyone to make a small difference.”

    Another angel advocate, Holly Armstrong, was also a living donor. She hopes her efforts will plant a seed.

    “Some people might just keep scrolling,” said Armstrong, who lives in Lake Wiley, South Carolina. “But there might be someone like me, where they stop scrolling and say, ‘This boy needs a kidney.’”

    A study released last year found that people who volunteer to donate a kidney are at a lower risk of death from the operation than doctors had previously thought. Tracking 30 years of living kidney donations, researchers found fewer than 1 in every 10,000 donors died within three months of the surgery. Newer and safer surgical techniques were credited for dropping the risk from 3 deaths per 10,000 living donors.

    Temple serves a large cohort of poorer patients who can have difficulty understanding health issues and who suffer from uncontrolled hypertension and diabetes, Ihlenfeldt, who works there, said.

    “What David’s trying to do is coalesce a network of support around these patients who are sharing the story for them,” Ihlenfeldt said.

    At a kickoff event in a Harrisburg meeting room for kidney patient Ahmad Collins, a couple dozen friends and family listened with rapt attention as Krissman went over the game plan, answering questions and describing the transplant process.

    Collins, a 50-year-old city government worker and former Penn State linebacker, has needed 10 hours a night of dialysis since a medical procedure left him with damaged kidneys late last year.

    His mind was on the strangers who might decide to pitch in.

    “They can be a superhero, so to speak,” Collins said. “They can have the opportunity to save somebody’s life, and not too many times in life do you have that opportunity.”

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  • Plant-Based Hospital Menus | NutritionFacts.org

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    The American Medical Association passed a resolution encouraging hospitals to offer healthy plant-based food options.

    “Globally, 11 million deaths annually are attributable to dietary factors, placing poor diet ahead of any other risk factor for death in the world.” Given that diet is our leading killer, you’d think that nutrition education would be emphasized during medical school and training, but there is a deficiency. A systematic review found that, “despite the centrality of nutrition to a healthy lifestyle, graduating medical students are not supported through their education to provide high-quality, effective nutrition care to patients…”

    It could start in undergrad. What’s more important? Learning about humanity’s leading killer or organic chemistry?

    In medical school, students may average only 19 hours of nutrition out of thousands of hours of instruction, and they aren’t even being taught what’s most useful. How many cases of scurvy and beriberi, diseases of dietary deficiency, will they encounter in clinical practice? In contrast, how many of their future patients will be suffering from dietary excesses—obesity, diabetes, hypertension, and heart disease? Those are probably a little more common than scurvy or beriberi. “Nevertheless, fully 95% of cardiologists [surveyed] believe that their role includes personally providing patients with at least basic nutrition information,” yet not even one in ten feels they have an “expert” grasp on the subject.

    If you look at the clinical guidelines for what we should do for our patients with regard to our number one killer, atherosclerotic cardiovascular disease, all treatment begins with a healthy lifestyle, as shown below and at 1:50 in my video Hospitals with 100-Percent Plant-Based Menus.

    “Yet, how can clinicians put these guidelines into practice without adequate training in nutrition?”

    Less than half of medical schools report teaching any nutrition in clinical practice. In fact, they may be effectively teaching anti-nutrition, as “students typically begin medical school with a greater appreciation for the role of nutrition in health than when they leave.” Below and at 2:36 in my video is a figure entitled “Percentage of Medical Students Indicating that Nutrition is Important to Their Careers.” Upon entry to different medical schools, about three-quarters on average felt that nutrition is important to their careers. Smart bunch. Then, after two years of instruction, they were asked the same question, and the numbers plummeted. In fact, at most schools, it fell to 0%. Instead of being educated, they got de-educated. They had the notion that nutrition is important washed right out of their brains. “Thus, preclinical teaching”— the first two years of medical school—“engenders a loss of a sense of the relevance of the applied discipline of nutrition.”

    Following medical school, during residency, nutrition education is “minimal or, more typically, absent.” “Major updates” were released in 2018 for residency and fellowship training requirements, and there were zero requirements for nutrition. “So you could have an internal medicine graduate who comes out of a terrific program and has learned nothing—literally nothing—about nutrition.”

    “Why is diet not routinely addressed in both medical education and practice already, and what should be done about that?” One of the “reasons for the medical silence in nutrition” is that, “sadly…nutrition takes a back seat…because there are few financial incentives to support it.” What can we do about that? The Food Law and Policy Clinic at Harvard Law School identified a dozen different policy levers at all stages of medical education and the kinds of policy recommendations there could be for the decision-makers, as you can see here and at 3:48 in my video.

    For instance, the government could require doctors working for Veterans Affairs (VA) to get at least some courses in nutrition, or we could put questions about nutrition on the board exams so schools would be pressured to teach it. As we are now, even patients who have just had a heart attack aren’t changing their diet. Doctors may not be telling them to do so, and hospitals may be actively undermining their future with the food they serve.

    The good news is that the American Medical Association (AMA) has passed a resolution encouraging hospitals to offer healthy food options. What a concept! “Our AMA hereby calls on [U.S.] Health Care Facilities to improve the health of patients, staff, and visitors by: (a) providing a variety of healthy food, including plant-based meals, and meals that are low in saturated and trans fat, sodium, and added sugars; (b) eliminating processed meats from menus; and (c) providing and promoting healthy beverages.” Nice!

    “Similarly, in 2018, the State of California mandated the availability of plant-based meals for hospital patients,” and there are hospitals in Gainesville (FL), the Bronx, Manhattan, Denver, and Tampa (FL) that “all provide 100% plant-based meals to their patients on a separate menu and provide educational materials to inpatients to improve education on the role of diet, especially plant-based diets, in chronic illness.”

    Let’s check out some of their menu offerings: How about some lentil Bolognese? Or a cauliflower scramble with baked hash browns for breakfast, mushroom ragu for lunch, and, for supper, white bean stew, salad, and fruit for dessert. (This is the first time a hospital menu has ever made me hungry!)

    The key to these transformations was “having a physician advocate and increasing education of staff and patients on the benefits of eating more plant-based foods.” A single clinician can spark change in a whole system, because science is on their side. “Doctors have a unique position in society” to influence policy at all levels; it’s about time we used it.

    For more on the ingrained ignorance of basic clinical nutrition in medicine, see the related posts below.

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    Michael Greger M.D. FACLM

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  • Rates of high blood pressure in children have nearly doubled in 20 years

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    (CNN) — Global rates of hypertension, or high blood pressure, in childhood and adolescence have nearly doubled since 2000, putting more kids at risk for poor health later in life.

    “In 2000, about 3.4% of boys and 3% of girls had hypertension. By 2020, those numbers had risen to 6.5% and 5.8% respectively,” said Dr. Peige Song, a researcher from the School of Public Health at Zhejiang University School of Medicine in China. Song is one of the authors of a study describing the findings that published Wednesday in the journal The Lancet Child and Adolescent Health.

    Children who have hypertension could be at greater risk later on of developing heart disease –– the No. 1 cause of death in the United States, said Dr. Mingyu Zhang, assistant professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center. He was not involved in the research.

    “The good news is that this is a modifiable risk,” Song said in an email. “With better screening, earlier detection, and a stronger focus on prevention, especially around healthy weight and nutrition, we can intervene before complications arise.”

    High blood pressure in kids can be addressed

    The rise in hypertension in children is likely due to many factors.

    Childhood obesity is a significant risk factor, because it is associated with factors like insulin resistance, inflammation and vascular function, Song said.

    Dietary factors such as consuming high levels of sodium and ultraprocessed food can also contribute to hypertension risk, as well as poor sleep quality, stress and genetic predisposition, she said.

    Many children also get less movement than past generations and spend more time on sedentary activities, like screen use, which may be affecting risk, she said.

    “We are also starting to know that other factors, including environmental pollutants, can contribute,” Zhang added.

    Zhang served as senior author on a previous study that showed a connection between prebirth exposure to chemicals called PFAS — a class of about 15,000 human-made compounds linked to cancers, endocrine-related conditions and developmental issues in children — and childhood hypertension. Short for perfluoroalkyl and polyfluoroalkyl substances, PFAS are sometimes called “forever chemicals” because they don’t fully break down in the environment.

    The biggest takeaway of this research for families is not to assume high blood pressure is only a problem for adults, Song said.

    If you are worried about your child’s risk for obesity or hypertension, pressure, shame and restriction are not the best approaches.

    Instead, focus on increasing healthy behaviors in a happy way, said Jill Castle, a pediatric dietitian in Massachusetts, in a previous CNN article.

    “The goal of the food pillar is really to embrace flexibility with food and to emphasize foods that are highly nutritious and … to allow foods also that might be minimally nutritious within the diet in ways that can be fully enjoyed and flexible,” Castle said.

    Try to prioritize sitting down as a family for meals and avoid labeling foods as “good” or “bad,” said Castle, author of “Kids Thrive at Every Size.”

    “The clean plate club or rewarding with sweets — they might work in the moment, but they don’t do a good job of establishing the self-trust and an intuitive, good relationship with food as kids grow up,” Castle said.

    Masked hypertension in children

    The study didn’t just track rates in the United States. Instead, researchers analyzed data from 96 studies across 21 countries.

    Another important consideration the study team made is how blood pressure differs in and outside the doctor’s office. Some children might have normal blood pressure at home, but a higher reading in the office, while others might have a lower blood pressure in the office than they normally would.

    By including data from both office visits and at-home blood pressure readings, the researchers were able to include hypertension rates that are “masked,” or wouldn’t be caught in a doctor’s visit, Zhang said. Masked hypertension was found to be the most common kind, according to the data.

    “This is important because it means that many children with true hypertension could go undetected if we rely only on office blood pressure readings,” he said.

    The result show that one reading may not be enough, and there may be a need for more scalable solutions for better monitoring and care of hypertension around the world, Song added.

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    Madeline Holcombe and CNN

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  • Ideal vs. Normal Cholesterol Levels  | NutritionFacts.org

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    Having a “normal” cholesterol level in a society where it’s normal to die from a heart attack isn’t necessarily a good thing.

    “Consistent evidence” from a variety of sources “unequivocally establishes” that so-called bad LDL cholesterol causes atherosclerotic cardiovascular disease—strokes and heart attacks, our leading cause of death. This evidence base includes hundreds of studies involving millions of people. “Cholesterol is the cause of atherosclerosis,” the hardening of the arteries, and “the message is loud and clear.” “It’s the Cholesterol, Stupid!” noted the editor of the American Journal of Cardiology, William Clifford Roberts, whose CV is more than 100 pages long as he has published about 1,700 articles in peer-reviewed medical literature. Yes, there are at least ten traditional risk factors for atherosclerosis, as seen below and at 1:11 in my video How Low Should You Go for Ideal LDL Cholesterol?, but, as Dr. Roberts noted, only one is required for the progression of the disease: elevated cholesterol.

    Your doctor may have just told you that your cholesterol is normal, so you’re relieved. Thank goodness! But, having a “normal” cholesterol level in a society where it’s normal to have a fatal heart attack isn’t necessarily good. With heart disease, the number one killer of men and women, we definitely don’t want to have normal cholesterol levels; we want to have optimal levels—and not optimal by current laboratory standards, but optimal for human health.

    Normal LDL cholesterol levels are associated with the hidden buildup of atherosclerotic plaques in our arteries, even in those who have so-called “optimal risk factors by current standards”: blood pressure under 120/80, normal blood sugars, and total cholesterol under 200 mg/dL. If you went to your doctor with those kinds of numbers, you’d likely get a gold star and a lollipop. But, if your doctor used ultrasound and CT scans to actually peek inside your body, atherosclerotic plaques would be detected in about 38% of individuals with those kinds of “optimal” numbers.

    Maybe we should define an LDL cholesterol level as optimal only when it no longer causes disease. What a concept! When more than a thousand men and women in their 40s were scanned, having an LDL level under 130 mg/dL left them with atherosclerosis throughout their body, and that’s a cholesterol level at which most lab tests would consider normal.

    In fact, atherosclerotic plaques were not found with LDL levels down around 50 or 60, which just so happens to be the levels most people had “before the introduction of western lifestyles.” Indeed, before we started eating a typical American diet, “the majority of the adult population of the world had LDLs of around 50 mg per deciliter (mg/dL)”—so that’s the true normal. “Present average values…should not be regarded as ‘normal.’” We don’t want to have a normal cholesterol based on a sick society; we want a cholesterol that is normal for the human species, which may be down around 30 to 70 mg/dL or 0.8 to 1.8 mmol/L.

    “Although an LDL level of 50 to 70 mg/dl seems excessively low by modern American standards, it is precisely the normal range for individuals living the lifestyle and eating the diet for which we are genetically adapted.” Over millions of years, “through the evolution of the ancestors of man,” we’ve consumed a diet centered around whole plant foods. No wonder we have a killer epidemic of atherosclerosis, given the LDL level “we were ‘genetically designed for’ is less than half of what is presently considered ‘normal.’”

    In medicine, “there is an inappropriate tendency to accept small changes in reversible risk factors,” but “the goal is not to decrease risk but to prevent atherosclerotic plaques!” So, how low should you go? “In light of the latest evidence from trials exploring the benefits and risks of profound LDLc lowering, the answer to the question ‘How low do you go?’ is, arguably, a straightforward ‘As low as you can!’” “‘Lower’ may indeed be better,” but if you’re going to do it with drugs, then you have to balance that with the risk of the drug’s side effects.

    Why don’t we just drug everyone with statins, by putting them in the water supply, for instance? Although it would be great if everyone’s cholesterol were lower, there are the countervailing risks of the drugs. So, doctors aim to use statin drugs at the highest dose possible, achieving the largest LDL cholesterol reduction possible without increasing risk of the muscle damage the drugs may cause. But when you’re using lifestyle changes to bring down your cholesterol, all you get are the benefits.

    Can we get our LDL low enough with diet alone? Ask some of the country’s top cholesterol experts what they shoot for, “and the odds are good that many will say 70 or so.” So, yes, we should try to avoid the saturated fats and trans fats found in junk foods and meat, and the dietary cholesterol found mostly in eggs, but “it is unlikely anyone can achieve an LDL cholesterol level of 70 mg/dL with a low-fat, low-cholesterol diet alone.” Really? Many doctors have this mistaken impression. An LDL of 70 isn’t only possible on a healthy enough diet, but it may be normal. Those eating strictly plant-based diets can average an LDL that low, as you can see here and at 5:28 in my video.

    No wonder plant-based diets are the only dietary patterns ever proven to reverse coronary heart disease in a majority of patients. And their side effects? You get to feel better, too! Several randomized clinical trials have demonstrated that more plant-based dietary patterns significantly improve psychological well-being and quality of life, with improvements in depression, anxiety, emotional well-being, physical well-being, and general health.

    For more on cholesterol, see the related posts below.

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    Michael Greger M.D. FACLM

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  • Are We Being Misled About the Benefits and Risks of Statins?  | NutritionFacts.org

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    What is the dirty little secret of drugs for lifestyle diseases?

    Drug companies go out of their way—in direct-to-consumer ads, for example—to “present pharmaceutical drugs as a preferred solution to cholesterol management while downplaying lifestyle change.” You see this echoed in the medical literature, as in this editorial in the Journal of the American Medical Association: “Despite decades of exhortation for improvement, the high prevalence of poor lifestyle behaviors leading to elevated cardiovascular disease risk factors persists, with myocardial infarction [heart attack] and stroke remaining the leading causes of death in the United States. Clearly, many more adults could benefit from…statins for primary prevention.” Do we really need to put more people on drugs? A reply was published in the British Medical Journal: “Once again, doctors are implored to ‘get real’—stop hoping that efforts to help their patients and communities adopt healthy lifestyle habits will succeed, and start prescribing more statins. This is a self-fulfilling prophecy. Note that the author of these comments [the pro-statin editorial] disclosed receipt of funding from 11 drug companies, at least four of which produce or are developing new classes of cholesterol-lowering agents,” which make billions of dollars a year in annual sales.

    Every time the cholesterol guidelines expand the number of people eligible for statins, they’re decried as a “big kiss to big pharma.” This is understandable, since the majority of guideline panel members “had industry ties,” financial conflicts of interest. But these days, all the major statins are off-patent, so there are inexpensive generic versions. For example, the safest, most effective statin is generic Lipitor, sold as atorvastatin for as little as a few dollars a month. So, nowadays, the cholesterol guidelines are not necessarily “part of an industry plot.”

    “The US way of life is the problem, not the guidelines…” The reason so many people are candidates for cholesterol- and blood-pressure-lowering medications is that so many people are taking such terrible care of themselves. The bottom line is that “individuals must take more responsibility for their own health behaviors.” What if you are unwilling or unable to improve your diet and make lifestyle changes to bring down that risk? If your ten-year risk of having a heart attack is 7.5 percent or more and going to stay that way, then the benefits of taking a statin drug likely outweigh the risk. That’s really for you to decide, though. It’s your body, your choice.

    “Whether or not the overall benefit-harm balance justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even the attending physician. Instead, it is the individual patient who has a fundamental right to decide whether or not taking a drug is worthwhile.” This was recognized by some of medicine’s “historical luminaries such as Hippocrates,” but “only in recent decades has the medical profession begun to shift from a paternalistic ‘doctor knows best’ stance towards one explicitly endorsing patient-centered, evidence-based, shared decision-making.” One of the problems with communicating statin evidence to support this shared decision-making is that most doctors “have a poor understanding of concepts of risk and probability and…increasing exposure to statistics in undergraduate and postgraduate education hasn’t made much difference.” But that understanding is critical for preventive medicine. When doctors offer a cholesterol-lowering drug, “they’re doing something quite different from treating a patient who has sought help because she is sick. They’re not so much doctors as life insurance salespeople, peddling deferred benefits in exchange for a small (but certainly not negligible) ongoing inconvenience and cost. In this new kind of medicine, not understanding risk is the equivalent of not knowing about the circulation of the blood or basic anatomy. So, let’s dive in and see exactly what’s at stake.

    Below and at 3:55 in my video Are Doctors Misleading Patients About Statin Risks and Benefits? is an ad for Lipitor. When drug companies say a statin reduces the risk of a heart attack by 36 percent, that’s the relative risk.

    If you follow the asterisk I’ve circled after the “36%” in the ad, you can see how they came up with that. I’ve included it here and at 3:56 in my video. In a large clinical study, 3 percent of patients not taking the statin had a heart attack within a certain amount of time, compared to 2 percent of patients who did take the drug. So, the drug dropped heart attack risk from 3 percent to 2 percent; that’s about a one-third drop, hence the 36 percent reduced relative risk statistic. But another way to look at going from 3 percent to 2 percent is that the absolute risk only dropped by 1 percent. So, in effect, “your chance to avoid a nonfatal heart attack during the next 2 years is about 97% without treatment, but you can increase it to about 98% by taking a Crestor [a statin] every day.” Another way to say that is that you’d have to treat 100 people with the drug to prevent a single heart attack. That statistic may shock a lot of people.

    If you ask patients what they’ve been led to believe, they don’t think the chance of avoiding a heart attack within a few years on statins is 1 in 100, but 1 in 2. “On average, it was believed that most patients (53.1%) using statins would avoid a heart attack after statin treatment for 5 years.” Most patients, not just 1 percent of patients. And this “disparity between actual and expected effect could be viewed as a dilemma. On the one hand, it is not ethically acceptable for caregivers to deliberately support and maintain illusive treatment expectations by patients.” We cannot mislead people into thinking a drug works better than it really does, but on the other hand, how else are we going to get people to take their pills?

    When asked, people want an absolute risk reduction of at least about 30 percent to take a cholesterol-lowering drug every day, whereas the actual absolute risk reduction is only about 1 percent. So, the dirty little secret is that, if patients knew the truth about how little these drugs actually worked, almost no one would agree to take them. Doctors are either not educating their patients or actively misinforming them. Given that the majority of patients expect a much larger benefit from statins than they’d get, “there is a tension between the patient’s right to know about benefiting from a preventive drug and the likely reduction in uptake [willingness to take the drugs] if they are so informed,” and learn the truth. This sounds terribly paternalistic, but hundreds of thousands of lives may be at stake.

    If patients were fully informed, people would die. About 20 million Americans are on statins. Even if the drugs saved 1 in 100, that could mean hundreds of thousands of lives lost if everyone stopped taking their statins. “It is ironic that informing patients about statins would increase the very outcomes they were designed to prevent.”

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    Michael Greger M.D. FACLM

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  • Should You Take Statins?  | NutritionFacts.org

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    How can you calculate your own personal heart disease risk to help you determine if you should start on a cholesterol-lowering statin drug?

    The muscle-related side effects from cholesterol-lowering statins “are often severe enough for patients to stop taking the drug. Of course, these side effects could be coincidental or psychosomatic and have nothing to do with the drug,” given that many clinical trials show such side effects are rare. “It is also possible that previous clinical trials”—funded by the drug companies themselves—“under-recorded the side effects of statins.” The bottom line is that there’s an urgent need to establish the true incidence of statin side effects.

    “What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug?” That’s the title of a journal article that reports that, even in trials funded by Big Pharma, “only a small minority of symptoms reported on statins are genuinely due to the statins,” and those taking statins are significantly more likely to develop type 2 diabetes than those randomized to placebo sugar pills. Why? We’re still not exactly sure, but statins may have the double-whammy effect of impairing insulin secretion from the pancreas while also diminishing insulin’s effectiveness by increasing insulin resistance.

    Even short-term use of statins may “approximately double the odds of developing diabetes and diabetic complications.” As shown below and at 1:49 in my video Who Should Take Statins?, fewer people develop diabetes and diabetic complications off statins over a period of about five years than those who do develop diabetes while on statins. “Of more concern, this increased risk persisted for at least 5 years after statin use stopped.”

    “In view of the overwhelming benefit of statins in the reduction of cardiovascular events,” the number one killer of men and women, any increase in risk of diabetes, our seventh leading cause of death, would be outweighed by any cardiovascular benefits, right? That’s a false dichotomy. We don’t have to choose between heart disease and diabetes. We can treat the cause of both with the same diet and lifestyle changes. The diet that can not only stop heart disease, but also reverse it, is the same one that can reverse type 2 diabetes. But what if, for whatever reason, you refuse to change your diet and lifestyle? In that case, what are the risks and benefits of starting statins? Don’t expect to get the full scoop from your doctor, as most seemed clueless about statins’ causal link with diabetes, so only a small fraction even bring it up with their patients.

    “Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.” But that’s for you to decide. Before we quantify exactly what the risks and benefits are, what exactly are the recommendations of current guidelines?

    How should you decide if a statin is right for you? “If you have a history of heart disease or stroke, taking a statin medication is recommended, without considering your cholesterol levels.” Period. Full stop. No discussion needed. “If you do not yet have any known cardiovascular disease,” then the decision should be based on calculating your own personal risk. If you know your cholesterol and blood pressure numbers, it’s easy to do that online with the American College of Cardiology risk estimator or the Framingham risk profiler.

    My favorite is the American College of Cardiology’s estimator because it gives you your current ten-year risk and also your lifetime risk. So, for a person with a 5.8 percent risk of having a heart attack or stroke within the next decade, if they don’t clean up their act, that lifetime risk jumps to 46 percent, nearly a flip of the coin. If they improved their cholesterol and blood pressure, though, they could reduce that risk by more than tenfold, down to 3.9 percent, as shown below and at 4:11 in my video.

    Since the statin decision is based on your ten-year risk, what do you do with that number? As you can see here and at 4:48 in my video, under the current guidelines, if your ten-year risk is under 5 percent, then, unless there are extenuating circumstances, you should just stick to diet, exercise, and smoking cessation to bring down your numbers. In contrast, if your ten-year risk hits 20 percent, then the recommendation is to add a statin drug on top of making lifestyle modifications. Unless there are risk-enhancing factors, the tendency is to stick with lifestyle changes if risk is less than 7.5 percent and to move towards adding drugs if above 7.5 percent.

    Risk-enhancing factors that your doctor should take into account when helping you make the decision include a bad family history, really high LDL cholesterol, metabolic syndrome, chronic kidney or inflammatory conditions, or persistently high triglycerides, C-reactive protein, or LP(a). You can see the whole list here and at 4:54 in my video.

    If you’re still uncertain, guidelines suggest you consider getting a coronary artery calcium (CAC) score, but even though the radiation exposure from that test is relatively low these days, the U.S. Preventive Services Task Force has explicitly concluded that the current evidence is insufficient to conclude that the benefits outweigh the harms.

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    Michael Greger M.D. FACLM

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  • Apple Watch Series 11 receives FDA approval for hypertension alerts

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    Apple’s Awe Dropping event started with dramatic health testimonials from Apple Watch users, then revealed a key new feature for the new Watch Series 11: hypertension alerts. The function had yet to receive FDA approval at the time, but that has now been granted, according to Bloomberg. As a result, it will reportedly be available to users in 150 countries when the Watch 11 and Ultra Watch 3 ship starting on September 19.

    Hypertension alerts can help detect hypertension (high blood pressure), a potentially dangerous condition that affects over a billion people. The feature relies on the Watch’s optical heart sensor, but now uses new machine learning algorithm that also draws from a study involving more than 100,000 participants to look for high blood pressure. It works in the background a month-long period to seek patterns associated with hypertension. Unlike devices that measure your specific blood pressure, it only tells users that there may be a danger.

    Last year, Apple received the FDA’s nod for its over-the-counter Hearing Aid function that transforms the second-gen AirPods Pro into OTC hearing aids for people with mild-to-moderate hearing loss. Another recently approved feature is sleep apnea detection. However, the company is currently facing a lawsuit over the Apple Watch’s redesigned blood oxygen monitoring feature.

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    Steve Dent

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  • Nearly half of people with diabetes don’t know they have it, new study finds

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    (CNN) — When was the last time you had your blood sugar checked? It might be worth looking into, a new study says.

    Forty-four percent of people age 15 and older living with diabetes are undiagnosed, so they don’t know they have it, according to data analysis published Monday in the journal The Lancet Diabetes & Endocrinology.

    The study looked at data from 204 countries and territories from 2000 to 2023 in a systematic review of published literature and surveys. The findings at the global level are for people age 15 and older.

    “The majority of people with diabetes that we report on in the study have type 2 diabetes,” said Lauryn Stafford , the lead author of the study.

    Around 1 in 9 adults live with diabetes worldwide, according to the International Diabetes Foundation. In the United States, 11.6% of Americans have diabetes, according to 2021 data from the American Diabetes Association.

    “We found that 56% of people with diabetes are aware that they have the condition,” said Stafford, a researcher for the Institute for Health Metrics and Evaluation. “Globally, there’s a lot of variation geographically, and also by age. So, generally, higher-income countries were doing better at diagnosing people than low- and middle-income countries.”

    Younger people don’t know they have diabetes

    People under 35 years were much less likely to be diagnosed if they had diabetes than people in middle age or older. Just “20% of young adults with diabetes were aware of their condition,” Stafford said.

    Routine screenings aren’t promoted as much for young adults as for older adults. Many larger organizations, like the American Diabetes Association, suggest annual routine screenings for adults 35 and older.

    “You can survive with elevated glucose levels for many, many years,” Stafford said. “People end up getting diagnosed with diabetes only at the point where they have complications,” which are more common in older adults.

    Depending on how long a person has had diabetes before it’s discovered, the health impacts may vary.

    “Diagnosing diabetes early is important because it allows for timely management to prevent or delay long-term complications such as heart disease, kidney failure, nerve damage, and vision loss,” said Rita Kalyani, chief scientific and medical officer at the American Diabetes Association. She was not involved in the study.

    Around one-third of adults are diagnosed with diabetes later than their earliest symptom, according to a 2018 study.

    What symptoms should you look for?

    “Symptoms of diabetes include increased thirst or hunger, frequent urination, blurry vision, unexpected weight loss, and fatigue. However, in the early stages, most people with diabetes are asymptomatic, which highlights the importance of screening and diagnosis,” said Kalyani, a professor of medicine in the division of endocrinology, diabetes and metabolism at Johns Hopkins University.

    If you experience any of these symptoms or have a history of diabetes in your family, experts recommend you get a glucose screening.

    Globally, in 2023, about 40% of people with treated diabetes were getting optimal results and lowering their blood sugar, said Stafford. That’s why it’s important that future efforts focus on ensuring that more people receive and follow proper treatment post-diagnosis.

    That only 4 in 10 patients were seeing optimal results was surprising, as several well-established treatments, including insulin, Metformin and other drugs like GLP-1s, are available.

    People with diabetes likely also have other health issues, such as hypertension or chronic kidney disease, which can make treatment complex, Stafford added.

    Can you prevent diabetes?

    It depends.

    While there is no known way to prevent type 1 diabetes, there are many ways to prevent the more common form of type 2 diabetes.

    Reducing the amount of red and processed meats you eat can help lower your risk of type 2 diabetes, as previously reported by CNN. You could do this with a Mediterranean diet or by introducing more plant-based foods to your meals.

    In addition, limit the amount of ultraprocessed foods you eat, adding more whole foods, like fruits and nuts, instead.

    Incorporating physical activity into your regular routine can also decrease your risk of developing not only diabetes but also other chronic diseases. Fast walking for at least 15 minutes a day is just one form of exercise you can do.

    “I think, ultimately, if we can also focus more on the risk factors for developing diabetes — preventing people from needing to be diagnosed in the first place — that is also critical,” Stafford said.

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  • Treat Type 1 Diabetes with a Plant-Based Diet?  | NutritionFacts.org

    Treat Type 1 Diabetes with a Plant-Based Diet?  | NutritionFacts.org

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    Is it possible to reverse type 1 diabetes if caught early enough?

    The International Journal of Disease Reversal and Prevention has already had its share of miraculous disease reversals with a plant-based diet. For instance, one patient began following a whole food, plant-based diet after having two heart attacks in two months. Within months, he experienced no more chest pain, controlled his cholesterol, blood pressure, and blood sugars, and also lost 50 pounds as a nice bonus. Yet, the numbers “do not capture the patient’s transformation from feeling like a ‘dead man walking’ to being in command of his health with a new future and life.” 

    I’ve previously discussed cases of reversing the autoimmune inflammatory disease psoriasis and also talked about lupus nephritis (kidney inflammation). What about type 1 diabetes, an autoimmune disease we didn’t think we could do anything about? In contrast to type 2 diabetes, which is a lifestyle disease that can be prevented and reversed with a healthy enough diet and lifestyle, type 1 diabetes is an autoimmune disease in which our body attacks our pancreas, killing off our insulin-producing cells and condemning us to a life of insulin injections—unless, perhaps, it’s caught early enough. If a healthy enough diet is started early enough, might we be able to reverse the course of type 1 diabetes by blunting that autoimmune inflammation?

    As I discuss in my video Type 1 Diabetes Treatment: A Plant-Based Diet, we know that patients with type 1 diabetes “may be able to reduce insulin requirements and achieve better glycemic [blood sugar] control” with healthier diets. For example, children and teens were randomized to a nutritional intervention in which they increased the whole plant food density of their diet—meaning they ate more whole grains, whole fruits, vegetables, legumes (beans, split peas, chickpeas, and lentils), nuts, and seeds. Researchers found that the more whole plant foods, the better the blood sugar control.

    The fact that more whole fruits were associated “with better glycemic [blood sugar] control has important clinical implications for nutrition education” in those with type 1 diabetes. We should be “educating them on the benefits of fruit intake, and allaying erroneous concerns that fruit may adversely affect blood sugar.”

    The case series in the IJDRP, however, went beyond proposing better control of just their high blood sugars, the symptom of diabetes, but better control of the disease itself, suggesting the anti-inflammatory effects of whole healthy plant foods “may slow or prevent further destruction of the beta cells”—the insulin-producing cells of the pancreas—“if dietary intervention is initiated early enough.” Where did this concept come from?

    A young patient. Immediately following diagnosis of type 1 diabetes at age three, a patient began a vegetable-rich diet and, three years later, “has not yet required insulin therapy…and has experienced a steady decline in autoantibody levels,” which are markers of insulin cell destruction. Another child, who also started eating a healthier diet, but not until several months after diagnosis, maintains a low dose of insulin with good control. And, even if their insulin-producing cells have been utterly destroyed, individuals with type 1 diabetes can still enjoy “dramatically reduced insulin requirements,” reduced inflammation, and reduced cardiovascular risk, which is their number one cause of death over the age of 30. People with type 1 diabetes have 11 to 14 times the risk of death from cardiovascular disease compared to the general population, and it’s already the top killer among the public, so it’s closer to 11 to 14 times more important for those with type 1 diabetes to be on the only diet and lifestyle program ever proven to reverse heart disease in the majority of patients—one centered around whole plant foods. The fact it may also help control the disease itself is just sugar-free icing on the cake.

    All this exciting new research was presented in the first issue of The International Journal of Disease Reversal and Prevention. As a bonus, there’s a companion publication called the Disease Reversal and Prevention Digest. These are for the lay public and are developed with the belief I wholeheartedly share that “everyone has a right to understand the science that could impact their health.” You can go behind the scenes and hear directly from the author of the lupus series, read interviews from luminaries like Dean Ornish, see practical tips from dietitians on making the transition towards a healthier diet, and enjoy recipes. 

    The second issue includes more practical tips, such as how to eat plant-based on a budget, and gives updates on what Dr. Klaper is doing to educate medical students, what Audrey Sanchez from Balanced is doing to help change school lunches, and how Dr. Ostfeld got healthy foods served in a hospital. (What a concept!) And what magazine would be complete without an article to improve your sex life? 

    The journal is free, downloadable at IJDRP.org, and its companion digest, available at diseasereversaldigest.com, carries a subscription fee. I am a proud subscriber.

    Want to learn more about preventing type 1 diabetes in the first place? See the related posts below.

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    Michael Greger M.D. FACLM

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  • The Largest Study on Fasting in the World  | NutritionFacts.org

    The Largest Study on Fasting in the World  | NutritionFacts.org

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    The Buchinger-modified fasting program is put to the test.

    A century ago, fasting—“starvation, as a therapeutic measure”—was described as “the ideal measure for the human hog…” (Fat shaming is not a new invention in the medical literature.) I’ve covered fasting for weight loss extensively in a nine-video series, but what about all the other purported benefits? I also have a video series on fasting for hypertension, but what about psoriasis, eczema, type 2 diabetes, lupus, metabolic disorder, rheumatoid arthritis, other autoimmune disorders, depression, and anxiety? Why hasn’t it been tested more?

    One difficulty with fasting research is: What do you mean by fasting? When I think of fasting, I think of water-only fasting, but, in Europe, they tend to practice “modified therapeutic fasting,” also known as Buchinger fasting, which is more like a very low-calorie juice fasting with some vegetable broth. Some forms of fasting may not even cut calories at all. As you can see below and at 1:09 in my video The World’s Largest Fasting Study, Ramadan fasting, for example, is when devout Muslims abstain from food and drink from sunrise to sunset, yet, interestingly, they end up eating the same amount—or even more food—overall.

    The largest study on fasting to date was published in 2019. More than a thousand individuals were put through a modified fast, cutting daily intake down to about ten cups of water, a cup of fruit juice, and a cup of vegetable soup. They reported very few side effects. In contrast, the latest water-only fasting data from a study that involved half as many people reported nearly 6,000 adverse effects. Now, the modified fasting study did seem to try to undercount adverse effects by only counting reported symptoms if they were repeated three times. However, adverse effects like nausea, feeling faint, upset stomach, vomiting, or palpitations were “observed only in single cases,” whereas the water-only fasting study reported about 100 to 200 of each, as you can see below and at 2:05 in my video. What about the benefits though?

    In the modified fasting study, participants self-reported improvements in physical and emotional well-being, along with a surprising lack of hunger. What’s more, the vast majority of those who came in with a pre-existing health complaint reported feeling better, with less than 10 percent stating that their condition worsened, as you can see in the graph below and at 2:24 in my video. 

    However, the study participants didn’t just fast; they also engaged in a lifestyle program, which included being on a plant-based diet before and after the modified fast. If only the researchers had had some study participants follow the healthier, plant-based diet without the fast to tease out fasting’s effects. Oh, but they did! About a thousand individuals fasted for a week on the same juice and vegetable soup regimen and others followed a normocaloric (normal calorie) vegetarian diet.

    As you can see below and at 2:54 in my video, both groups experienced significant increases in both physical and mental quality of life, and, interestingly, there was no significant difference between the groups.

    In terms of their major health complaints—including rheumatoid arthritis; chronic pain syndromes, like osteoarthritis, fibromyalgia, and back pain; inflammatory and irritable bowel disease; chronic pulmonary diseases; and migraine and chronic tension-type headaches—the fasting group appeared to have an edge, but both groups did well, with about 80 percent reporting improvements in their condition and only about 4 percent reporting feeling worse, as you can see below and at 3:25 in my video. 

    Now, this was not a randomized study; people chose which treatment they wanted to follow. So, maybe, for example, those choosing fasting were sicker or something. Also, the improvements in quality of life and disease status were all subjective self-reporting, which is ripe for placebo effects. There was no do-nothing control group, and the response rates to the follow-up quality of life surveys were only about 60 to 70 percent, which also could have biased the results. But extended benefits are certainly possible, given they all tended to improve their diets, as you can see below and at 4:00 in my video.

    They ate more fruits and vegetables, and less meats and sweets, and therein may lie the secret. “Principally, the experience of fasting may support motivation for lifestyle change. Most fasters experience clarity of mind and feel a ‘letting go’ of past actions and experiences and thus may develop a more positive attitude toward the future.”

    As a consensus panel of fasting experts concluded, “Nutritional therapy (theory and practice) is a vital and integral component of fasting. After the fasting therapy and refeeding period, nutrition should follow the recommendations/concepts of a…plant-based whole-food diet…”

    If you missed the previous video, check out The Benefits of Fasting for Healing.

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    Michael Greger M.D. FACLM

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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    Michael Greger M.D. FACLM

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  • Testing for Vitamin B12 Deficiency  | NutritionFacts.org

    Testing for Vitamin B12 Deficiency  | NutritionFacts.org

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

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

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

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

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

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

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

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

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

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

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

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    Michael Greger M.D. FACLM

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Stay tuned for: 

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    Michael Greger M.D. FACLM

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  • The Stroke Risk of Vegetarians  | NutritionFacts.org

    The Stroke Risk of Vegetarians  | NutritionFacts.org

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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    Michael Greger M.D. FACLM

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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    Michael Greger M.D. FACLM

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  • Lose Weight by Eating More in the Morning  | NutritionFacts.org

    Lose Weight by Eating More in the Morning  | NutritionFacts.org

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    A calorie is not a calorie. It isn’t only what you eat, but when you eat.

    Mice are nocturnal creatures. They eat during the night and sleep during the day. However, if you only feed mice during the day, they gain more weight than if they were fed a similar amount of calories at night. Same food and about the same amount of food, but different weight outcomes, as you can see in the graph below and at 0:18 in my video Eat More Calories in the Morning to Lose Weight, suggesting that eating at the “wrong” time may lead to disproportionate weight gain. In humans, the wrong time would presumably mean eating at night. 

    Recommendations for weight management often include advice to limit nighttime food consumption, but this was largely anecdotal until it was first studied experimentally in 2013. Researchers instructed a group of young men not to eat after 7:00 pm for two weeks. Compared to a control period during which they continued their regular habits, they ended up about two pounds lighter after the night-eating restriction. This is not surprising, given that dietary records show the study participants inadvertently ate fewer calories during that time. To see if timing has metabolic effects beyond just foreclosing eating opportunities, you’d have to force people to eat the same amount of the same food, but at different times of the day. The U.S. Army stepped forward to carry out just such an investigation.

    In their first set of experiments, Army researchers had people eat a single meal a day either as breakfast or dinner. The results clearly showed the breakfast group lost more weight, as you can see in the graph below and at 1:35 in my video. When study participants ate only once a day at dinner, their weight didn’t change much, but when they ate once a day at breakfast, they lost about two pounds a week. 

    Similar to the night-eating restriction study, this is to be expected, given that people tend to be hungrier in the evening. Think about it. If you went nine hours without eating during the day, you’d be famished, but people go nine hours without eating overnight all the time and don’t wake up ravenous. There is a natural circadian rhythm to hunger that peaks around 8:00 pm and drops to its lowest level around 8:00 am, as you can see in the graph below and at 2:09 in my video. That may be why breakfast is typically the smallest meal of the day. 

    The circadian rhythm of our appetite isn’t just behavioral, but biological, too. It’s not just that we’re hungrier in the evening because we’ve been running around all day. If you stayed up all night and slept all day, you’d still be hungriest when you woke up that evening. To untangle the factors, scientists used what’s called a “forced desynchrony” protocol. Study participants stayed in a room without windows in constant, unchanging, dim light and slept in staggered 20-hour cycles to totally scramble them up. This went on for more than a week, so the subjects ended up eating and sleeping at different times throughout all phases of the day. Then, the researchers could see if cyclical phenomena are truly based on internal clocks or just a consequence of what you happen to be doing at the time.  

    For instance, there is a daily swing in our core body temperature, blood pressure, hormone production, digestion, immune activity, and almost everything else, but let’s use temperature as an example. As you can see in the graph below and at 3:21 in my video, our body temperature usually bottoms out around 4:00 am, dropping from 98.6°F (37°C) down to more like 97.6°F (36.4°C). Is this just because our body cools down as we sleep? No. By keeping people awake and busy for 24 hours straight, it can be shown experimentally that it happens at about the same time no matter what. It’s part of our circadian rhythm, just like our appetite. It makes sense, then, if you are only eating one meal per day and want to lose weight, you’d want to eat in the morning when your hunger hormones are at their lowest level. 

    Sounds reasonable, but it starts to get weird.

    The Army scientists repeated the experiment, but this time, they had the participants eat exactly 2,000 calories either as breakfast or as dinner, taking appetite out of the picture. The subjects weren’t allowed to exercise either. Same number of calories, so the same change in weight, right? No. As you can see in the graph below and at 4:18 in my video, the breakfast-only group still lost about two pounds a week compared to the dinner-only group. Two pounds of weight loss eating the same number of calories. That’s why this concept of chronobiology, meal timing—when to eat—is so important. 

    Isn’t that wild? Two pounds of weight loss a week eating the same number of calories! That was a pretty extreme study, though. What about just shifting a greater percentage of calories to earlier in the day? That’s the subject of my next video: Breakfast Like a King, Lunch Like a Prince, Dinner Like a Pauper. First, let’s take a break from chronobiology to look at the Benefits of Garlic for Fighting Cancer and the Common Cold. Then, we’ll resume checking other videos in the related posts below.

    If you missed the first three videos in this extended series, also check out related posts below. 

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    Michael Greger M.D. FACLM

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

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

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

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

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

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

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

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

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

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

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

    What else can garlic do? See related posts below.

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

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

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    Michael Greger M.D. FACLM

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