For Clear, Healthy Skin, Take Care of the Gut

Eczema is a troubling skin condition that affects millions of Americans.  The itchy rash of eczema is due to an atopic reaction: an inappropriate inflammatory response by the immune system.  One thing that has long been known to help eczema, especially the type associated with food allergies, is the use of probiotics supplements (those beneficial bacteria).  Sometimes we think of probiotics as only helping with digestive problems, but their beneficial effects extend throughout the body.  These effects range from helping with obesity to depression to autism.

A new review study (1) clarified the effects of probiotics in eczema and food allergies.  The author clarified that probiotics taken orally have a balancing effect on our immune system (immunomodulation).  This is because most of our immune tissue is located along the lining of our digestive tract.  The interaction of probiotic bacteria with these immune cells sends chemical signals to the immune system in the rest of the body, to make sure it's not overactive or under-active.  Think of it as a toning workout for our immune system.

Probiotic supplementation seems to be most effective at preventing and treating eczema from ages 0 to 2.  Prenatal probiotic supplementation by the mother can also have a strong preventive effect.

The type of probiotic matters, also.  The most beneficial effect was seen with Lactobacillus rhamnosus, but the author emphasized that the chief consideration for immunomodulation is the diversity of microbes in the gut.  For this, it's important to maintain a high fiber diet, to provide the prebiotic nutrients necessary to feed these helpful critters.  Another key to microbial diversity is to declare a truce in the "war on bugs:"  let your kids play in the dirt.  Get rid of the antibacterial hand soaps.  Take it easy on the Clorox wipes.  By decreasing our exposure to germs, this kind of over-attention to hygiene may actually be one of the big contributors to the increased incidence of allergies and eczema over the last couple of decades.

1.  Kuitunen M.  Probiotics and Prebiotics in Preventing Food Allergy and Eczema.  Curr Opin Allergy Clin Immunol. 2013;13(3):280-286. 

Another Key to Childhood Behavioral Problems: Avoid This at All Costs

Aggression.  Inattention.  These issues just seem to be getting more and more prevalent in kids all the Time these days.  Last month, I told you how inadequate sleep can greatly increase the risk of aggressive behavior in children.  Recent research has uncovered another culprit in this growing problem:  soft drinks.

Researchers at Columbia University in New York examined almost 3000 children, looking at the average soda consumption and behavioral habits of five-year-olds.  They used maternal reports of the amount of soda consumed, and an assessment called the Child Behavior Checklist (CBCL).  The results?  Even one soda per day significantly increased problem behaviors.  And with higher soda consumption, the aggression just gets worse.  Four soft drinks per day doubled the score for inattention and withdrawn behavior, and almost quintupled the aggression score, compared to kids who drank no soda.  These differences remained significant even after controlling for other factors, such as intake of other sweets, level of physical activity, and maternal depression.

Interestingly, the researchers did not differentiate among types of soft drinks: regular versus diet, caffeinated versus decaffeinated.  So it is unclear whether this is an issue with sugar, caffeine, or just a marker of an overall poor diet.  Not surprisingly, the American Beverage Association capitalized on this uncertainty to state that this study does not prove that soft drinks cause any problem behaviors.  Sure.  Just like they have said that artificial sweeteners are a good alternative to sugar, when science has shown that diet soda is linked to dangerously increased stroke risk and diabetes risk in adults.

To me, this is just another reason to say that pop is an unnecessary health risk, no matter what your age.

Sugila S et al.  Soft Drinks Consumption Is Associated with Behavior Problems in 5-Year-Olds.  J Peds 21 August 2013.

Are You Missing This Important Supplement for Childhood Behavioral Problems?

Behavioral problems in children often start during the preschool years.  Making sure that kids have a healthy, balanced diet, as well as plenty of physical activity, can make a big difference in kids' behavior.  One "supplement" that is becoming more overlooked these days is one of the foundations of health in naturopathic medicine: sleep.

Recent research from the Albert Einstein College of Medicine in New York City (1) examined almost 9000 preschool aged children, and looked at the relationship between sleep and behavior.  They found that kids who average fewer than 9.44 hours of sleep per night have a 30 to 40% higher rate of anger, impulsivity, overactivity, and tantrums.  Significantly, these kids were also 80% more likely to be aggressive.  More than two hours of television viewing per night was also associated with worse overall behavior.

Inadequate sleep for adults may result in mood problems, increased pain sensitivity, and even a greater risk of diabetes and cardiovascular disease.  Now, we have further evidence of just one more way that sleep is critical for kids as well.  Follow these guidelines to ensure a good nights rest for your little ones:

• Stick with a scheduled bedtime and wake-up time.  Aim for at least 10 hours of sleep per night.  So if the kids have to be up at 7 AM, make sure they're in bed by 9 PM.
• Turn off all screens (TV, computer, smartphone, tablet, etc.) at least one hour before bedtime.
• Keep the bedroom cool and dark to make falling asleep easier.
• If your child is having trouble falling asleep, consult your naturopathic physician before trying any sleep aid -- even natural ones.

1.  Scharf RJ et al.  Nighttime Sleep Duration and Externalizing Behaviors of Preschool Children.  J Dev Behav Pediatr. 2013;34:384-391.

Coffee: Superfood or Death Sentence?

Earlier this year, I outlined some of the amazing health benefits associated with regular coffee consumption.  These include a decrease risk of chronic diseases such as diabetes, Alzheimer's disease, and endometrial cancer; pain reduction as among its benefits too.

Now, new research from the Mayo Clinic (1) makes us pause and reflect on how much is too much of a good thing.  I often hammer that old adage, "all things in moderation;" in this case, moderation appears to be 4 cups of coffee per day.  More than that raises the risk of death for people under age 55.

Researchers looked at data from the Aerobics Center Longitudinal Study, which examined dietary habits and health data from over 43,000 participants over the course of 31 years.  For folks under the age of 55 who drank more than 28 cups of coffee per week, all-cause mortality risk increased by over 50% for men, and more than doubled for women.  The direct cause of this association is unknown, but seems to be unrelated to coffees cardiovascular effects.

One of the important points to keep in mind is that a "cup" in this study is defined as 8 fluid ounces; the cutoff point therefore seems to be about 32 ounces per day.  The "cup" markers on your coffee pot are 6 ounces each, so the limit would be about five of those cups.  If you prefer to get your coffee on the go, this would translate into only two "grandes."

This study leaves a lot of questions, such as the association of caffeine on health (the study didn't differentiate between regular and decaf coffee), the actual biological mechanisms of coffee (it has hundreds of phytochemicals besides caffeine), and the confounding factor of smoking with coffee consumption.  In the meantime...  Come on, people, four cups per day should be plenty for anyone.  In fact, beyond the first one or two cups of the day, why not explore the benefits of other healthful beverages such as green tea?

1.  Liu J, Sui X, Lavie CJ, et al. Association of coffee consumption with all-cause and cardiovascular disease mortality.Mayo Clin Proc 2013; DOI:10.1016/j.mayocp.2013.06.020.

Amazing Breakthrough for Depression - You Won't Believe What It Is!

Depression is not just "feeling blue," but rather a significant mental health condition that can affect one's whole life.  The CDC estimates that one in 10 American adults is depressed.  Depression goes hand-in-hand with poor outcomes in chronic health conditions like cancer, diabetes, cardiovascular disease, and obesity, in addition to the more obvious negatives social and behavioral effects.

For this reason, antidepressants have become one of the most widely prescribed classes of drugs in the US over the last 20 years.  The most common of these are the SSRIs, such as Prozac (fluoxetine).  While these medications can help people to live more normal and productive lives, they do come with significant side effects, such as sleep disturbances, loss of libido, weight gain, and even an increase in suicidal ideation.

There is good research about natural alternatives for mild to moderate depression, such as aerobic exercise and St. John's wort.  Exciting new research out of India has highlighted a safe alternative for major depression: curcumin.  Curcumin is the active compound in the herb turmeric.  This was a relatively small study, involving 60 patients with major depressive disorder.  They were divided into three groups: one group received fluoxetine, 20 mg daily; the second group received curcumin, 1000 mg daily; the third group received a combination of the two.  Outcomes were measured using the Hamilton Depression rating scale.  There was no statistical difference in the response rate among the three groups, and at the end of six weeks, the change in Hamilton score was comparable in all three groups.

This is big news.  Depression is a serious health condition, but the side effects of SSRIs are further complicated by the difficulty that patients have in coming off these medications.  On the contrary, the "side effects" of curcumin include:

• protection against neurodegenerative diseases such as Parkinson's and Alzheimer's,
• enhanced gastrointestinal health,
• protection of the liver against toxins,
• anti-inflammatory effects from muscles and joints,
• and more.  

One thing to keep in mind about curcumin, however, is that most standardized extracts are poorly absorbed from the intestinal tract.  It is best to use curcumin that is complexed with phosphatidylcholine (such as Curamin [BCM-95--the type used in this study] or Meriva), or used in conjunction with black pepper (piperine).

A last note of caution: if you are currently taking antidepressant medications, do not discontinue them abruptly.  Consult with your prescribing physician about weaning down gradually on the dosage, to avoid withdrawal effects.  It is perfectly safe, however, to start taking curcumin while still on the pharmaceutical antidepressant.

1.  Efficacy and Safety of Curcumin in Major Depressive Disorder: A Randomized Controlled Trial.  Phytother Res. 2013 Jul 6. doi: 10.1002/ptr.5025. [Epub ahead of print]

More News about the Gut's Role in Autism

Last week, I highlighted new evidence about the link between gluten and the symptoms of autistic spectrum disorder (ASD).  Hot off the presses, we have another study about a gut-autism link.  Researchers at Arizona State University (1) found a significant difference between the normal flora (bacteria in the gastrointestinal tract) of children with autism and non-autistic children.  In particular, autistic children had lower levels of three types of bacteria:  Prevotella, Coprococcus, and Veillonellaceae.  These were identified from fecal samples taken from children ages 3 to 16 years.  These organisms, especially Prevotella, are important for carbohydrate digestion, and maintenance of healthy biodiversity in the gut ecosystem.  Impairment of carbohydrate digestion may leave these kids more susceptible to developing the leaky gut and gluten sensitivity described in last week's article.

While this research is intriguing, it still presents us with a chicken-or-egg dilemma: do disturbances of gut bacteria contribute to the development of ASD, or are children with ASD more susceptible to gut flora imbalances by some other mechanism?  We are only in the very early stages of identifying all the complexities of the trillions of microorganisms that live inside of us.  Now that we have identified the human genome, the next step is to tackle the human microbiome:  the identification of all of those microbial species in their proper proportions to maintain good health.

Over the next 20 years or so, our current probiotics supplements will look like primitive stone tools.  Hopefully, we can get to the stage where we can supplement with specific organisms like the ones identified in this study (none of which are available in current probiotics supplements).  Otherwise, we may have to look more seriously at fecal microbiota transplantation as an important technique for many health conditions, not just C. difficile infection.

Related posts:

• I Have a Gut Feeling They're on to Something.  
• Good Bacteria = Smaller Waistline?

1.  Kang D-W, Park JG, Ilhan ZE, Wallstrom G, LaBaer J, et al. (2013) Reduced Incidence of Prevotella and Other Fermenters in Intestinal Microflora of Autistic Children. PLoS ONE 8(7): e68322. doi:10.1371/journal.pone.0068322

New Evidence on the Link between Gluten and Autism

Rates of autism have been on the rise in the US over the last few decades.  The exact cause of this is unknown; part of the reason may be due to an increased degree of awareness and diagnosis.  This uncertainty is reflected in a major change to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5): the terms autistic disorder, Asperger's syndrome, and pervasive developmental disorder have been replaced by the single umbrella term autistic spectrum disorder (ASD).  Holistic doctors and concerned parents continue to search for therapies that can help mitigate the symptoms of autism in any way.  One of the cornerstones of this natural approach has been a gluten-free diet.

The theory behind this is that children with ASD are particularly susceptible to a compromised barrier in the gastrointestinal (GI) tract -- a condition known as "leaky gut".  This allows larger "chunks" of protein to make it into the bloodstream without being fully digested.  Gluten, the main protein in wheat and related grains, can contribute to this GI damage.  The gluten protein in the bloodstream can also stimulate an immune system response; the resulting inflammation can have an impact on the nervous system, exacerbating autistic behaviors.

New research out of Italy (1) demonstrated that children with ASD have a higher rate of IgG antibodies to gluten than healthy children of the same age.  They did not have higher rates of lab markers for celiac disease, such as tissue transglutaminase antibodies, and the HLA-DQ2 and HLA-DQ8 genes.  This indicates that there is a continuum of sensitivity to gluten other than full-blown celiac disease.

While the authors of the study are cautious in their interpretation of these results, it just adds more support to the naturopathic approach of a gluten elimination diet, along with nutritional and herbal therapies to help repair the lining of the GI tract.  A gluten-free diet is not easy under the best of circumstances in our culture; for autistic children, who often have very strong food preferences, it can be even more difficult.  However, with the prospect of significant behavioral improvement, it's definitely worth a try.

1.  Lau NM, Green PHR, Taylor AK, Hellberg D, Ajamian M, et al. (2013) Markers of Celiac Disease and Gluten Sensitivity in Children with Autism. PLoS ONE 8(6): e66155. doi:10.1371/journal.pone.0066155

Pomi-T: One More Follow-Up

Well, I was unable to locate the authentic Pomi-T supplement for prostate cancer, but an astute patient found a UK supplier that will ship to the U.S.:

http://www.powerhealth.co.uk/products-detail.asp?productid=2002

For more information, check their main web site.

Ladies, Improve Your Sleep Quality 800% With This Simple Fix

In the dog days of summer, "women of a certain age" probably know well the difficulty of getting a good night's sleep, especially when dealing with postmenopausal hot flashes.  The benefits of sleep cannot be overstated in terms of our overall health.  Inadequate sleep can lead to diabetes, obesity, elevated blood pressure, and even certain types of cancer.  Fortunately, there is a natural remedy for this situation; it is as close as your sneakers, and costs nothing.

Yes, once again, it's my favorite supplement: exercise.  In March 2013, a study published in the journal Menopause found that women with high levels of leisure time physical activity over eight times as likely to experience good sleep quality.  While the authors did not quantify exactly what types or how much physical activity was involved, we can presume that any activity is better than being sedentary.  It's amazing how much of our leisure time is taken up with electronic screens: computers, TVs, iPads, smartphones... we never have to be without these magical devices that keep our brains engaged, while allowing our bodies to wallow in torpor.

So get out there, and enjoy some walking, biking, swimming, or gardening, and get a better night's rest tonight.

Physical activity and sleep among midlife women with vasomotor symptoms.  Menopause. Published online March 25, 2013. 

Pomi-T Follow Up...
My article about the beneficial effects of a new botanical supplement, Pomi-T, for prostate cancer patients brought a flood of interested feedback.  However, I have been hard-pressed to find the actual product.  It was produced by a British company called nature Medical Products, and sold out as a response to the publicity about the research study.  An internet search yielded no further reliable information about the availability of Pomi-T or nature Medical Products.  So until we have a source for Pomi-T in the U.S., keep eating your veggies, and look for other standardized supplements for pomegranate, broccoli, green tea, and curcumin (turmeric extract).

Will Fat Kill You, or Make You Live Forever?

As you might expect, it depends on the kind of fat.  As I wrote about a few weeks ago, the standard advice from the 1970s and 80s about following a low-fat diet turned out to be less healthy than including "good" fats from foods like nuts and olive oil.  Another recent scientific paper from Australia, published in the British Medical Journal, further blows to top off the old dietary fats advice, showing that saturated fat may not be as bad as we thought it was.

A few decades ago, researchers started noticing a correlation between intake of saturated fats (from foods like meat, dairy products, and shortening) and cardiovascular disease.  The recommendation, therefore, was to replace these fats with healthier polyunsaturated fats from vegetable sources.  In this study, researchers examined data about 458 men, half of whom received advice to replace saturated fats with omega-6 oils from vegetable sources.  The other half (the control group) received no specific dietary advice.  After about seven years, it turned out that the death rate in the omega-6 group was 17.6%, versus 11.8% in the control group.  Heart disease rates were also 60% higher in the vegetable oil group.

Wait.  Take a look at those numbers.  Don't we all know that a saturated fat laden cheeseburger will just clog up our arteries as we're sitting there?  Isn't this why all the lard and shortening have been replaced with "healthy" vegetable oil for frying?

It turns out that not all polyunsaturated fats are created equal.  There are two major categories of PUFAs:  omega-6 and omega-3.  Ideally, the ratio of our intake of omega-6 to omega-3 should be about 2 to 1.  A higher intake of omega-3 fatty acids has been shown over and over again to decrease cardiovascular disease risk, and lower mortality rates.  However, the current ratio in America is about 20 to 1, omega-6 to omega-3.  This is a major reason why chronic degenerative diseases continue to escalate in this country.  Maybe it's those french fries that are killing us, not the burgers.

So what are we to do with this information?  No, this is not carte blanche to go and scarf down as much meat as you want; we still know that a plant-based eating pattern such as the Mediterranean diet is highly protective overall.  For cooking, use smaller amounts of healthy saturated fat, such as extra-virgin coconut oil.  Extra-virgin olive oil is also a good choice, as a source of monounsaturated fats (and yes, contrary to popular belief, you absolutely can cook with it).  A fish oil supplement is a must for most people, to ensure adequate omega-3 intake.  Skip deep-fried foods altogether, since the omega-6 fats in the vegetable oils may actually increase our mortality risk (either by themselves, or by transformation into trans fats).

The more we learn, the more we'll untangle which fats are good for us!

Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis.  BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8707 (Published 5 February 2013).

Conventional Medical Doctors Acknowledge Supplement for Prostate Cancer

Conventional physicians are not always known for their open-mindedness about natural therapies, such as nutritional and herbal supplements.  However, in light of good scientific research, they cannot keep their eyes closed to the benefits.

Results of a new research study were presented at the 2013 annual meeting of the American Society of Clinical Oncology that showed a new supplement led to significant lowering of prostate specific antigen (PSA) levels in prostate cancer patients.  This was a randomized placebo-controlled trial, which is considered the highest level of scientific evidence available in the medical world.  The supplement, called Pomi-T, is a combination of well-known cancer fighting botanicals, including turmeric, green tea, broccoli, and pomegranate.

This study examined 203 men who had been treated for prostate cancer, but had a relapse of elevated PSA.  Half of the subjects were randomized to receive Pomi-T, and half received a placebo.  After six months, the botanicals group had a 63.8% lower increase in PSA versus the placebo group.  They were also three times as likely to have stable or even lower than baseline PSA levels versus the placebo group.  Furthermore, there were no significant side effects from the supplement.

The medical community, which historically has been skeptical, if not downright antagonistic, towards nutritional supplements, heralded this research for two important reasons.  Firstly, the design and quality of the supplement was closely monitored.  This is important, since many off-the-shelf supplements are questionable in terms of their quality and purity.  Secondly, this study was well designed, and had enough subjects to draw good statistical conclusions.  Many times, when you read about "clinical research" on a supplement manufacturer's website, this is based on a handful of subjects, with no placebo control.

Remember, too, that any supplement is an addition to a healthy lifestyle: good diet and regular exercise.  But if you are dealing with prostate cancer, this supplement looks like a good fit.  If you can't find it, you can find supplemental forms of each of the components; just be sure to get standardized products from reputable manufacturers.  When it comes to cancer, don't bet your life on the cheap stuff off the shelf at Wal-Mart.

2013 Annual Meeting of the American Society of Clinical Oncology. Abstract 5008. Presented June 3, 2013.

Fish Oil is Dead... or Is It?

If you're a patient or a regular reader of my articles, you know that one supplement that I often recommend is fish oil -- a good source of omega-3 fatty acids.  These fats are essential to our health, because our bodies cannot make them from any other type of fat.  The many benefits of omega-3 fats include:

• Cardiovascular health benefits
• Immunomodulation
• Anti-inflammatory effects
• Psychological and behavioral health improvement
• Improved bone density

A large study published recently in the New England Journal of Medicine (1) has called into serious question the well-established cardiovascular benefits of fish oil.  Italian researchers divided a group of over 12,000 subjects into two groups:  one received 1 gram of omega-3 fats from fish oil per day, the other 1 gram of placebo (olive oil).  These were high-risk patients:  people with multiple cardiovascular risk factors such as high cholesterol, type 2 diabetes, or even established atherosclerosis.  The outcome?  After 1 year, there was no difference in the rates of death, non-fatal heart attack, or stroke between the two groups.

What are we to conclude from this?  The sound-bite headlines trumpet "Fish Oil is Worthless!"  Some eminent cardiologists agree.  But let's peel back the layers, and examine the flaws in this otherwise large and impressive study.

1.  Dose.  1 gram of omega-3 fats is not a high dose at all, especially in this population of high-risk patients.  For my patients with any cardiovascular risk factors, I recommend 1.5-2.5 grams of omega-3 fats per day.  And remember, a 1 gram (1000 mg) fish oil softgel only contains about 300 mg of omega-3s.  For cardiovascular health, 5-8 softgels per day are required.  An alternative would be to take a concentrated form of fish oil, or to use liquid cod liver oil.  I take about 2 teaspoons of cod liver oil daily, which supplies around 2.5 grams (2500 mg) of omega-3s.
2. Quality.  There is a wide variability in the quality of fish oil products.  A pharmaceutical-grade form is best, which is screened for impurities, and has less chance of being rancid.  The form used in the study is not specified.
3. Lab Values.  One of the main ways that omega-3 fats benefit the cardiovascular system is by lowering triglyceride levels -- data about patients' triglyceride levels were not included in the study.  Also, how well were the diabetic patients maintaining blood sugar control?  Poorly controlled blood sugar is a major risk factor that a little fish oil won't overcome.
4. Choice of "Placebo."  A placebo (inactive pill) is necessary in research studies to compare to the active intervention, to account for the fact that people's expectations about receiving care can have a strong therapeutic effect.  This is know as the placebo effect.  But is olive oil a good choice as an inert comparison?  There is a mountain of research about the cardiovascular benefits of the Mediterranean Diet, whose foundation is daily olive oil use.  Just a few weeks ago, I wrote about the PREDIMED study, which found that an olive oil-supplemented Mediterranean diet resulted in a 30 percent decreased risk of cardiovascular disease. 
5. Other Benefits of Omega-3 Fats.  Now granted, the list of other benefits was not being looked at in this study, but some commentators really threw the baby out with the bathwater on this point.  Cardiologist Eric Topol, MD, called fish oil a "no-go," a "nada effect," and even "implores" his patients to stop taking it.  Really?  That's quite an exercise in ignoring the large body of research on fish oil for multiple body systems.

As always, I urge you to look past the headlines, and consider the whole research picture.  Don't throw out your fish oil on the basis of this one flawed study.

1.  n–3 Fatty Acids in Patients with Multiple Cardiovascular Risk Factors.  N Engl J Med 2013; 368:1800-1808May 9, 2013DOI: 10.1056/NEJMoa1205409

I Have a Gut Feeling They're on to Something.

You know you're mostly not human, right?

When you count the microorganisms living in your gastrointestinal tract, skin, and respiratory tract will, there are ten times as many bacterial cells as human cells in your body.  We are ecosystems, rather than single organisms.  If 20th century nutrition was the discovery of vitamins, proteins, carbohydrates, and other nutrients, 21st century nutrition will be the study of how nutrients affect those 90% of nonhuman cells within us.

These friendly bacteria (also known as normal flora or probiotics) play an important role in our gastrointestinal health, allergies, normal immune system functioning, and maintaining a normal body weight.  Some intriguing early animal studies found that probiotics could even decrease symptoms of depression.  In the June issue of the journal Gastroenterology, researchers at UCLA published the first study showing a direct effect of probiotics on the human brain.  And no, this does not mean that people were shoving yogurt into their ears.

Researchers divided a group of 36 healthy women into three subgroups: the first received two servings of yogurt with probiotics daily; the second subgroup received non-fermented milk products; and the third subgroup received no special foods.

After four weeks, these women underwent psychological testing while in a functional MRI (fMRI) -- an imager that examines real-time brain activity, rather than just taking a static image.  The probiotic subgroup showed significantly reduced activity in brain areas associated with emotional variability and pain.  Translation?  Probiotics made them less moody!

The importance of this study is that it proves that gut bacteria can have a direct impact on human brain functioning, specifically in the areas of emotions and pain perception.  It did not examine what the exact mechanism of action is.  We also have to be a bit cautious with this study, because these were healthy volunteers, with no gastrointestinal or psychological disorders.

Nevertheless, this just adds another piece of evidence that indicates that tending to the complex "rain forest" within us, with fermented foods and lots of dietary fiber, is probably more important than taking high doses of any single nutrient.

Tillisch K et al.  Consumption of Fermented Milk Product With Probiotic Modulates Brain Activity.  Gastroenterology June 2013; 144(7):1394-1401.

More Good News for the Mediterranean Diet

For years, the standard nutritional advice for cardiovascular disease prevention has been to follow a low-fat diet.  This is still the official recommendation of the American Heart Association.  However, more and more evidence is pointing to the fact that it may be the quality, not quantity, of the fats we consume that is good for our hearts.

A few weeks ago, I wrote about a new study showing that detrimental effects of red meat consumption on our gut bacteria.  This could be one of the keys that links higher risk of cardiovascular disease to hiding meat intake.  The Mediterranean diet, which is low in meat, has just gotten some new support for its effectiveness in primary prevention of cardiovascular disease.  The Mediterranean diet is definitely not low in fat; it just relies more on different types of fat than the standard American diet (S.A.D.).  Instead of high levels of animal-based saturated fats from meat and dairy, the Mediterranean approach relies more on the healthful unsaturated fats in nuts and olive oil.

This new study from Spain, called PREDIMED (1), differs from previous research, in that it was a randomized controlled trial, involving over 7000 older men and women without any established cardiovascular disease.  This means that the investigators assigned a different diet to different groups of subjects -- either Mediterranean, or the AHA low-fat diet.  Most previous research was a retrospective -- that is, it looked at people's dietary habits in the past, based on recall or diet diaries.

The exciting finding from PREDIMED is that the Mediterranean diet, with a special focus on either olive oil or nuts, resulted in about a 30% lower risk of heart attack, stroke, or cardiovascular death compared to the low-fat approach.  Perhaps surprisingly, there are no studies of similar quality to support the benefits of a low-fat diet.  This recommendation of the AHA could be classified as a medical myth.

Dr Ramón Estruch, one of the lead researchers in this study, summarized his recommendations this way:

"People should know that the Mediterranean diet is a diet healthier than others and should know the key components of this food pattern. The plan should be to increase the intake of the key foods (vegetables, fruit, nuts, fish, legumes, extra virgin olive oil, and red wine in moderation), also increase the intake of white meat, and decrease the intake of red and processed meat, soda drinks, whole dairy products, commercial bakery goods, and sweets and pastries."

He continued: "To achieve a score of 14 in the 14-item adherence scale to traditional Mediterranean diet [laid out in a supplemental appendix in the paper] is more or less impossible, but to upgrade two to three points in this score is enough to reduce your cardiovascular risk by 30%."

 1.  Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; DOI:10.1056/NEJMoa200303. 

Just Say NO to High Blood Pressure!

It has long been known that compounds known as nitrates have a beneficial effect for the cardiovascular system.  The most common example of this is nitroglycerin, a drug that is used for angina (chest pain due to spasm of blood vessels).  Nitrates are transformed by bacteria in the mouth to nitrites, which are then converted in the blood into nitric oxide (NO).  NO relaxes blood vessels, which can lower blood pressure.

In addition to pharmaceutical nitrates, attention has been focused recently on whole foods sources of nitrates.  Two studies took a look at the effects of beetroot juice on blood pressure.  In 2012, Australian researchers (1) found that consuming beetroot juice significantly lowered systolic blood pressure for up to 6 hours, compared to placebo.  Beets are a good source of nitrates, which the body can convert into NO.

But 500 g of beetroot juice is quite a bit.  Some clever Brits (2) therefore compared drinking liquid beetroot juice to consuming a special beetroot enriched bread.  They found that both were equally effective in lowering blood pressure, and the bread may be more palatable.  Furthermore, in their study, they noticed that the blood pressure lowering benefits persisted for 24 hours.

One caveat to keep in mind is that both of these studies were performed with healthy subjects.  However, eating more vegetables is definitely good for your health anyway, so increasing your beet intake is a good idea if you're trying to lower your blood pressure.  You can also look at other vegetables that are high in nitrates, such as radishes, carrots, and lettuce.  And don't forget the blood pressure lowering benefits of chocolate for dessert!

1.  Coles, L and Clifton, P.  Effect of beetroot juice on lowering blood pressure in free-living, disease-free adults: a randomized, placebo-controlled trial.  Nutr J. 2012; 11: 106.

2.  Hobbs DA, et al. Blood pressure-lowering effects of beetroot juice and novel beetroot-enriched bread products in normotensive male subjects. Br J Nutr. 2012 Dec 14;108(11): 2066-74. Epub 2012 Mar 14.

Red Meat and Heart Health: The Gut Bacteria Connection

There's been a lot of debate over the years as to whether or not red meat consumption increases our risk of developing heart disease. In the past, much of the research has focused on the high levels of saturated fat and red meat, and their impact on blood cholesterol levels. A new study just published this month in Nature Medicine suggests a new mechanism: the difference in the type of gut bacteria between meat eaters and non-meat eaters.  A nice summary of the study was discussed recently on the National Public Radio show, Science Friday.

The main focus of this new study is a compound called L-carnitine, which is found in abundance in red meat. The intestinal bacteria found in omnivorous humans (compared to vegetarians or vegans) are more likely to metabolize L-carnitine into a compound called trimethylamine-N-oxide (TMAO).  High levels of TMAO accelerate the process of atherosclerosis.

The findings of this study are consistent with the well-known pattern of the Mediterranean diet, which places a great emphasis on plant-based foods, and recommends red meat only once or twice per month (see the pyramid diagram below). The Mediterranean diet is the pattern of eating among people in Italy, Greece, and other Mediterranean regions, that has been associated with protection against chronic disease, and greater lifespan.  This study has generated considerable outrage and debate, especially among proponents of high-meat diets, such as the Paleo diet. However, there is much more research about the health benefits of a Mediterranean eating pattern.

Once again, we're just beginning to scratch the surface of the importance of the ecosystem living in our intestinal tract.  I recently reported that the normal flora living in our gut can have an influence on obesity and weight loss.  If the first hundred years of nutrition research has focused on identifying nutrient compounds, deficiency conditions, and toxicity, then the next hundred years could be looking more at the effects of normal flora on our health.

Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis.  

Nature Medicine

 

(2013)

 

doi:10.1038/nm.3145.  

Published online

 

07 April 2013

Coffee: Pain Reduction, Weight Loss, and More

For decades, it's been a given in natural health circles that coffee is a no-no. It's commonly one of the first things that people are asked to give up when going on a detox program, or any other recommendations for improving their health. Over the past decade or so, though, evidence has been mounting that there are actually many health benefits for that morning cup of joe.

One of the latest findings is that coffee may help to reduce pain.  In 2012, Norwegian researchers found that coffee drinkers reported about a 25% lower pain score than non-coffee drinkers in a simulated office work environment. This difference was true whether participants had chronic pain or not.

Other benefits that have been reported for coffee in recent years include:

• decreased risk of endometrial cancer, Parkinson's disease, Alzheimer's disease, and type 2 diabetes
• enhanced muscle growth
• assistance with weight loss (with green coffee bean extract)

The research on green coffee extract for weight loss was a small human trial, involving only 16 subjects. Doses used were in the range of 700 to 1000 mg per day.  However, the results were striking, and so far, and this supplement seems safe. It is inexpensive, and worth a try for a few months.

The main benefits of coffee seem to be related to its phytonutrient content-- those health promoting compounds found in plants that have antioxidant and other beneficial effects on the human body. These benefits seem to hold true whether the coffee contains caffeine or not. So if you're concerned about caffeine, due to its acute blood pressure raising effects, or its detrimental effects on sleep, you can drink decaf, and still enjoy the preventive medicine aspects of coffee.

One last thing to keep in mind: many of the health benefits of coffee can be counteracted if you add a lot of milk and sugar to it. The high saturated fat and empty calories would be more than enough to outweigh the phytonutrient effects.

For me, I'll be enjoying my cup of black half-caf in the morning all the more.

Chocolate: Health Food or Not?

At this time of year, perhaps you've finished off your Valentine's Day chocolate, only to be looking forward to some chocolate in your Easter basket soon.  Americans definitely need to cut down on sweets:  The high sugar and saturated fat content in most milk chocolate can be a contributor to obesity and metabolic syndrome (a combination of insulin resistance, high blood pressure, and abnormal blood lipid levels).

On the other hand, the evidence for the health benefits of chocolate have been accumulating more and more in recent years.  The perks seem to be related to the flavanol content of the cocoa bean (Theobroma cacao).  The higher the cocoa (cacao) content, the better:  and dark chocolate (55% cacao or higher) is your best bet.  Eating an average of about one ounce per day can really boost cardiovascular and general health, including:

• Decreasing stroke risk by 14% for women (1) or 17% for men (2)
• Decreasing risk of heart failure in older women by 26-32% (3)
• Modestly reducing blood pressure (4-7)
• Decreasing "bad" cholesterol (LDL), and increasing "good" cholesterol (HDL) (8-9)
• Improving cognitive function (10)
• Most surprising of all:  decreasing body mass index (BMI) (11).  In other words, chocolate can lead to weight loss!

Just remember to enjoy your dark chocolate in moderation, as part of an overall nutrient-dense Mediterranean-type diet, including lots of fruits and veggies, nuts, legumes, lean protein, and healthy fats such as extra virgin olive oil.

1. Larsson SC, Virtmo J, Wolk A. Chocolate consumption and risk of stroke in women. J Am Coll Cardiol. 2011;58:1828-1829.
2. Larsson SC, Virtamo J, Wolk A. Chocolate consumption and risk of stroke: a prospective cohort of men and meta-analysis. Neurology. 2012;79:1223-1229.
3. Mostofsky E, Levitan EB, Wolk A, Mittleman MA. Chocolate intake and incidence of heart failure: a population-based prospective study of middle-aged and elderly women. Circ Heart Fail. 2010;3:612-616.
4. Ried K, Sullivan TR, Fakler P, Franks OR, Stocks NP. Effect of cocoa on blood pressure. Cochrane Database Syst Rev. 2012;8:CD008893.
5. Buijsse B, Weikert C, Drogan D, Bergmann M, Boeing H. Chocolate consumption in relation to blood pressure and risk of cardiovascular disease in German adults. Eur Heart J. 2010;31:1616-1623.
6. Taubert D, Roesen R, Lehmann C, Jung N, Schömig E. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: a randomized controlled trial. JAMA. 2007;298:49-60.
7. Buijsse B, Feskens EJ, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006;166:411-417.
8. Jia L, Liu X, Bai YY, et al. Short-term effect of cocoa product consumption on lipid profile: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2010;92:218-225.
9. Mursu J, Voutilainen S, Nurmi T, et al. Dark chocolate consumption increases HDL cholesterol concentration and chocolate fatty acids may inhibit lipid peroxidation in healthy humans. Free Radic Biol Med. 2004;37:1351-1359.
10. Desideri G, Kwik-Uribe C, Grassi D, et al. Benefits in cognitive function, blood pressure, and insulin resistance through cocoa flavanol consumption in elderly subjects with mild cognitive impairment: the Cocoa, Cognition, and Aging (CoCoA) study. Hypertension. 2012;60:794-801.
11. Golomb BA, Koperski S, White HL. Association between more frequent chocolate consumption and lower body mass index. Arch Intern Med. 2012;172:519-521.

Good Bacteria = Smaller Waistline?

Research in the area of normal flora -- the "good," or beneficial bacteria that live in our gut -- has been exploding in recent years.  It has been known for a long time that supplementing with probiotics (those friendly bacteria like Lactobacillus and Bifidus) can help with conditions ranging from eczema to allergies to irritable bowel syndrome.  But the list of benefits of proper microbial balance keeps growing -- and it seems like the more we know, the more we realize how much we don't know yet.

Recently, Chinese researchers (1) found a connection between the microbes in our gut and the problem of obesity.  Mice that were bred to be resistant to obesity, in spite of a high-fat diet, rapidly gained weight when injected with a bacteria from the human gut called Enterobacter cloacae.  They hypothesize that a harmful substance produced by these bacteria, called endotoxin, contributes to insulin resistance.  Insulin resistance is a major contributor to overeating and obesity, and the hallmark of type 2 diabetes.  Think of insulin as a key to open the door to your cells so they can take in blood sugar for energy; insulin resistance is where the lock on the cell doors gets worn and rusty, making it more difficult for insulin to do its job.  Insulin levels rise, which contributes to widespread inflammation in the cardiovascular system, and promotes fat storage.

In the same article, the researchers report a case study of a man who lost 66 pounds in 9 weeks by switching to a diet that promoted good bacteria growth in the intestinal tract.  The harmful Enterobacter was reduced to undetectable levels.

Now before you pop an acidophilus supplement or grab a Yoplait, expecting miraculous weight loss, we need to look a little more closely at the diet supplied to this test subject.  It was very high in fiber, to feed the good bacteria in the gut, and also included traditional Chinese fermented foods that might seem challenging to our palates.  Fermented foods are beginning to look more important than probiotic supplements, simply because of sheer numbers:  supplements might have anywhere from 1 billion to 20 billion bacteria per serving, which sounds like a lot, until you realize that there are about 100 trillion bacteria in your gut!  Traditional fermented foods have much higher levels of good bacteria than supplements.  We're not talking about most commercial yogurts, which are crammed with sugar and have questionable amounts of active bacterial cultures; we're talking about plain yogurt, kefir, miso, traditional sauerkraut, and kimchi, to name a few.

We've barely scratched the surface on research into our normal flora -- not just in the gastrointestinal tract, but also on the skin, respiratory tract, and genitourinary tract.  It makes sense that they would have such a huge influence on our health:  there are ten times as many bacterial cells as human cells in our bodies!  We are really more of an ecosystem rather than a single organism.  Perhaps in the future there will be much less emphasis on therapeutic nutrition, except as it applies to how it influences our flora.

1.  An opportunistic pathogen isolated from the gut of an obese human causes obesity in germfree mice.  The ISME Journal advance online publication 13 December 2012; doi: 10.1038/ismej.2012.153

To Calcium or Not to Calcium?

Two big studies that came out recently have muddied the waters on the one nutritional supplement that even conventional medicine has rallied behind:  calcium.

We've all heard that supplemental calcium is good for the bones, and may even protect against colon cancer in older adults.  Seems like a logical recommendation.  But like hormone replacement therapy, whose cardiovascular benefits were disproven ten years ago by the Women's Health Initiative study, calcium supplements are now being called into question.

The first chink in the armor came a few weeks ago when a study sponsored by the National Institutes of Health (NIH) (1) found that supplemental calcium boosts the risk of death by cardiovascular disease (CVD) in men, but not women.  Men who consumed 1000 mg/day of calcium supplement had a 20% higher risk of CVD death than those who took no calcium.

OK, great... men, ditch the calcium; women, keep popping those ginormous horse pills.  Until February 13, when BMJ (British Medical Journal) (2) published the findings of Swedish scientists, who found that calcium supplements increased death rates in women, too.  Examining the findings more closely, though, we find some important details:  the all-cause mortality rates were doubled in women with a calcium intake of  more than 1400 mg/day, compared to those getting 600-1000 mg/day.  A further complication is that risk of death was increased if the calcium came from supplements rather than food.

The US Preventive Services Task Force (3) has also chimed in, with a re-analysis of older data that showed that 400 IU of vitamin D plus 1000 mg of calcium per day did not significantly prevent fractures in healthy older women.

These studies add more weight to hints that have been accumulating over the years, that just increasing calcium intake is not necessarily better for health.  Some cultures of the world have very low levels of calcium intake, but very little osteoporosis.  Meanwhile, the US recommendations for daily calcium have climbed over the years, so that now the RDA for women over age 50 is 1200 mg/day.  When it comes to bone health, just adding more calcium is like throwing more bricks on a construction site, and hoping that they'll form a building.  You also need an architect and foreman -- namely, vitamin D and vitamin K.

So how do we parse all this confusion about calcium, health, and disease for older adults?  Here's my bottom line:

• Men:  Keep your daily calcium intake under 1000 mg/day.  For most men, this means skipping the calcium supplements altogether.
• Women:  Ditch the high-dose calcium supplements that provide 1000-1500 mg/day.  Aim for that 600-1000 mg/day range total between dietary and supplemental calcium, with an emphasis on dietary sources (dairy, leafy greens, sardines).
• Men and women:  Get your blood tested for 25-hydroxyvitamin D on a regular basis; aim for a level between 40-80 ng/ml.  If it is low, you may safely take higher levels of supplemental vitamin D3 (consult your doctor for the right amount -- I usually recommend anywhere from 2,000-10,000 IU per day).  If you have CVD, osteoporosis, or risk factors for these conditions, be sure to get extra vitamin K along with vitamin D3.

Stay tuned; like all of nutritional science, the landscape and recommendations are constantly in flux.

1.  Xiao Q, Murphy RA, Houston DK, Harris TB, Chow WH, Park Y. Dietary and supplemental calcium intake and cardiovascular disease mortality. JAMA Intern Med 2013; DOI:10.1001/jamainternmed.2013.3283. 

2.  Long term calcium intake and rates of all cause and cardiovascular mortality: community based prospective longitudinal cohort study.  BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f228 (Published 13 February 2013)

3.  

Vitamin D and Calcium Supplementation to Prevent Fractures in Adults: U.S. Preventive Services Task Force Recommendation Statement.  Ann Intern Med. 26 February 2013

Another Nail in the Coffin for Diet Soda

All right, Dr. Peters, will you lay off the diet-soda-bashing melodrama?

No.  The answer is no.

You've read my articles before about how diet soda actually promotes weight gain rather than weight loss, and more seriously, raises the risk of stroke significantly.  Is that Diet Coke fix worth a brain attack that could lead to permanent neurologic deficit, or even death?

Now French researchers have published findings (1) that consumption of lots of diet soda more than doubles the risk of developing type 2 diabetes, compared to non-soda drinkers.  This is an even higher risk than regular soda drinkers!  As you know, type 2 diabetes is like aging on fast forward, accelerating the development of cardiovascular disease, nerve problems, kidney disease, eye problems, and other complications.  But wait -- how much is "a lot" of diet soda?  More than about 600 ml per week.  Or for us Americans, about 20 fluid ounces.  Yes, just one 20 oz. bottle per week.  Know anyone who drinks more pop than that?

So let's look at the arguments of the beverage industry:

• "Diet soda is a good choice for those trying to lose weight, since it contains zero calories."  FALSE
• "Diet soda is a good choice for diabetics, since it contains no sugar."  FALSE

Consider the alternatives:

• Get a reusable water bottle, and make pure water your go-to drink.  Add a squirt of real lemon or lime juice for a little flavor, if you miss it.  No need to replace one highly processed food (diet soda) with another ("designer" waters).
• Green tea:  go beyond the Lipton -- there are many different varieties, with flavors that should appeal to everyone.  And how about a 20-30% lower risk of cardiovascular disease as a bonus?

1.  Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes in the Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l'Education Nationale–European Prospective Investigation into Cancer and Nutrition cohort.  January 30, 2013, doi: 10.3945/​ajcn.112.050997.  Am J Clin Nutr March 2013 ajcn.050997

What's Wrong with a Little Snack?

...Nothing, as long as it does not turn into a big snack.

One of the major factors that has been consistently found to influence weight gain or loss is controlling portion size.  Sometimes this is easier said than done -- for example, at buffets where the available portions are seemingly endless.

Researchers at Cornell University (1) recently ran an experiment to test this in a new way.  They gave two groups of people different serving sizes of snack foods (chocolate, pie, and potato chips) -- either small or large portions.  Of course, the choice of foods was not ideal (unless you count the health benefits recently coming to light for chocolate), but the point of the study was to look at calorie intake.  Not surprisingly, the small serving group took in fewer calories -- an average of 100 fewer.  What was important, though, is that they found no difference in reported satisfaction between the two groups.

This highlights a major principle of our food consumption:  the difference between hunger and appetite.  Hunger is the physiological need for food, detected and driven by the hypothalamus in the brain.  Appetite is the psychological desire for food, which can be the result of numerous factors -- one of which might be how much we have available in front of us.

So if you're going to have a snack, remember these principles:

• Measure out a small serving of snack ahead of time.  Don't grab the whole bag.
• Eat slowly -- give your brain a chance to catch on to that feeling of a satisfied appetite before reaching for more.

1.  Van Kleef, Ellen, Mitsuru Shimizu and Brian Wansink (2013). Just a bite: Considerably smaller snack portions satisfy delayed hunger and craving, Food Quality and Preference, 27(1):96-100

Exercise for Weight Loss: Take a Hint from Goldilocks

This is the time of year when many folks' New Year's resolutions include shedding a few (or a lot) of those excess pounds.  A healthy, balanced diet with proper portion control is the place to start, of course.  And starting an exercise program has tremendous health benefits, even beyond the waistline.  New research suggests, though, that more is not necessarily better -- even with something as healthy as physical activity.

Researchers at the University of Copenhagen in Denmark (1) explored the question of the effect of amount of exercise on weight loss.  They looked at overweight sedentary men, dividing them into three groups:

• a control group (no exercise)
• moderate exercise (300 calories burned per day, or about 30 minutes of running or cycling)
• high exercise (600 calories burned, or about 60 minutes per day)

After 13 weeks, they examined weight loss in the three groups.  Not surprisingly, the control group showed no change in weight.  The high-exercise group lost an average of about five pounds -- respectable, but actually less than expected, given the number of calories these gentlemen were burning.  But the moderate exercisers actually lost more weight:  about seven pounds on average, or forty percent more than the high-exercise group!  What could account for this Goldilocks effect -- not too much, not too little, but just right?

There is one major factor that the researchers did not examine:  body composition.  In other words, how much muscle and fat did each subject have at the beginning and end of the study?  The high exercisers were probably gaining more muscle than the moderate group, resulting in a lower net weight loss.  For this reason, I like to measure body composition (via bioimpedance analysis) at my clinic to more accurately track changes over time.  Lead scientist Mads Rosenkilde admits that if the study extended beyond 13 weeks, the metabolic benefit of increased muscle mass might become more noticeable in the high exercisers.

Nevertheless, there are at least two major pitfalls that the researchers identified for the high-exercise group.  The increase in calories burned seemed to lead to a compensatory increase in food intake -- this was most likely unconscious, a result of altered hormonal control over hunger signals (the set point theory).  A unique aspect of this study is that the subjects were equipped with motion sensors, to record their physical activity outside of the formal exercise periods.  The high exercisers were actually more sedentary the rest of the day compared to the moderate group -- perhaps due to fatigue, or perhaps they just felt they "deserved" more rest.

This study gives us plenty of food for thought on physical activity.  But like everything, let's take it in the context of all research, not just the latest headline:

• Any exercise is better than none at all.
• If you are using a lower intensity exercise such as walking, it might take 45-60 minutes to hit that 300 calorie burn goal.
• Short bursts of high-intensity exercise have been shown to have greater metabolic benefit overall than prolonged sessions of more moderate intensity exercise:  The improvement in insulin sensitivity can lead to better weight management with as little as 60 minutes per week. (2)

1.  Body fat loss and compensatory mechanisms in response to different doses of aerobic exercise--a randomized controlled trial in overweight sedentary males.  Am J Physiol Regul Integr Comp Physiol. 2012 Sep 15;303(6):R571-9. doi: 10.1152/ajpregu.00141.2012. Epub 2012 Aug 1.

2.  Just HIT it! A time-efficient exercise strategy to improve muscle insulin sensitivity.  J Physiol. 2010 September 15; 588(Pt 18): 3341–3342.

Seeds of Heart Health for the New Year

You've probably heard my mantra for a healthy diet (borrowed from author Michael Pollan):  "Eat food.  Not too much.  Mostly plants."  To expand on this, we can look to the Mediterranean diet -- that style of eating that is based on whole grains, vegetables, nuts, legumes (beans), and smaller amounts of animal-based protein.  This simple approach works well for maintaining a healthy body weight, and preventing chronic diseases such as cardiovascular disease.

A review (1) in the journal Clinical Lipidology (yes, you read that right; "lipidology" means the study of cholesterol and other fats) looks at dietary factors most associated with lowering cholesterol.

"The foods with the most evidence for cholesterol reduction are nuts, legumes, whole cereals rich in soluble fiber, and cocoa and its main commercial product, chocolate."

OK -- this sounds a lot like the Mediterranean diet.  What the author goes on to point out, though, is that all of these foods are actually seeds.  Obvious once someone points it out, isn't it?  Yet with as many years as I've taught patients and students about nutrition, this struck me as a beautifully concise revelation.  Even whole grains like oats are seeds.  And chocolate?  Yes, please!

Seeds contain fiber, healthy fats, and disease-busting phytonutrients.  Think of them as plant foods bursting with concentrated potential.

1.  Ros E.  How Important Is Dietary Management in Hypercholesterolemia?  Clin Lipidology. 2012;7(5):489-492.