Doctor, What Should I Eat?

Since I approach nutrition from a health standpoint, I'm always writing and talking about nutrients: fiber, protein, fats, etc. But most of us don't think in these terms; we think about eating in terms of food. So when it comes to translating my recommendations for a Mediterranean type diet into actual meal planning, where do you begin? Particularly if you don't have much experience with cooking, or you live alone, it can feel overwhelming to think about preparing healthy meals.

Fortunately, there are plenty of resources out there. Beyond the usual cookbooks, there are also websites that can help you out. If you are particularly trying to cut down on sugar, Dr. Mark Hyman has the perfect program for you, with his 10-Day Detox Diet -- either online or in print. For general healthy meal planning, there is a free website called the Dr. Gourmet Diet Plan that holds your hand into the world of the Mediterranean diet, step by step and recipe by recipe.  This site even has different plans for singles, families, diabetics, gluten-free, and more.  For even more recipe ideas, check out the down-to-earth blog Eating Rules.

And at the grocery store, don't forget about the handy NuVal tags to make quick comparisons on which foods are the best choices.

So the next time you hear the advice to increase your veggies or decrease your sugar intake, you now have a roadmap on how to actually implement that in your life.

Beyond the Paleo: Is it Really the Perfect Diet?

There has been explosive interest in the last few years in eating like our ancient, pre-agricultural ancestors:  following a hunter-gatherer pattern that would have been the norm in the Paleolithic Era (the "stone age").  The idea behind this is that agriculture has only been around for about 10,000 years, which is barely a blip on the evolutionary time scale.  Therefore, our genes are still adapted mostly to eating grass-fed meat, eggs, fish, fruits, nuts, and vegetables.  Foods that were introduced with agriculture - especially grains and beans - are harder to digest, and (so the logic goes) may actually contribute to health problems.

With my studies of biology in college, I am all on board the argument of genetic adaptation.  However, I think we need to look at the Paleo Diet critically to determine if it's really the healthiest way to eat.

• Peer-reviewed, published scientific studies about the Paleo Diet (of which there are fewer than ten) have mainly focused on short-term changes in specific parameters, like body weight, blood sugar, and blood cholesterol levels.  While there is definite benefit in these areas, the research has not gone as far as to prove lower risk of chronic disease or mortality (i.e., risk of dying early).
• The complete elimination of grains contradicts many studies that show decreased risk of chronic metabolic diseases.  Last month, Chinese researchers published data on over 367,000 participants, showing decreased all-cause mortality (that is, dying for any reason) with high consumption of fiber-rich whole grains.
• The argument that our genes have not had time to adapt to an agricultural diet ignores some biological nuances.  Sometimes genetic mutations can confer an advantage, and spread quickly -- the best example of this is the ability to produce the lactase enzyme into adulthood, which appeared just a few thousand years ago.  This allowed some populations to survive better than their neighbors, by taking advantage of dairy as a source of nutrition.  Another wrinkle is the relatively new field of epigenetics, which has found that though our genetic code may not change much, certain genes may be "turned on" or "turned off" (biochemically) in response to environmental pressures.  This can happen within a single generation, and the changes can even be passed on to offspring.

The Paleo Diet can serve some important functions.  As a structured system, it is a good way to break our addiction to sugar and refined carbohydrates, which is one of the leading causes of chronic disease.  By eliminating many common foods, the Paleo Diet can also serve as a tool to help identify foods that may be causing inflammatory reactions in the body.  For the long term, however, I still recommend the Mediterranean Diet (including - gasp! - whole grains), which has a mountain of evidence on improved health outcomes and longer lifespan.

Good Nutrition Made Even Easier

If there's one thing that's consistent in the field of nutrition, it's that information is always changing.  With the barrage of latest headlines about the scientific research on nutrition, how can we cut through the confusion and make healthy choices?  I usually spend a fair amount of time reading Nutrition Facts labels at the grocery store, weighing the pros and cons of each item.

Enter NuVal:  a user-friendly information system at the grocery store.  NuVal was developed by top nutrition researchers, led by David Katz, MD, of Yale.  It combines all the latest research about what makes a food healthy, and giving it a single numerical score from 1 (worst) to 100 (best).  The formula is complex, taking into account factors such as fiber, vitamins and minerals, sodium, calories, sugar, trans fats, and more -- but the end result is one simple number.

The best part of NuVal?  For grocery stores that choose to use it, it's right on the shelf, in black and white.  I first heard of this new system at a nutrition seminar last fall, and was surprised when I noticed the NuVal numbers on the shelf tags at Meijer a few weeks ago.  The numbers are small, so you have to squint a bit to read them, but they are there.  This is a very convenient way to compare foods in the same category, so you can quickly make better nutritional choices.

White pasta?

Or how about some whole grain pasta -- 30 points higher!

Yikes!  Just because a food is "organic" does not mean it's a healthy choice.

Of course, you still have to get a balanced diet of different types of healthy foods (ideally based around a Mediterranean-type pattern) -- you can't eat all asparagus all the time just because it has a NuVal of 100.  But if you can "trade up" to higher NuVal scores within the categories of foods you like, you'll notice the difference in your health.

Is It Time to Eat? A Surprisingly Important Question

'Tis the season for making New Year's resolutions.  Perhaps your resolutions include healthier eating and losing weight.  There is certainly plenty of info in my past articles on how to construct a healthy diet that will help you live longer and prevent chronic diseases. One element that may have been overlooked in all the scrutiny over what to eat is when to eat. There is growing evidence that restricting our eating to certain times of the day leads to more easily maintaining a healthy body weight.

Several authors and experts have been touting so-called "intermittent fasting," which consists of only eating between the hours of 10 AM and 6 PM, for example. Another version of this approach involves eating normally five days per week, but essentially fasting (taking in less than 500 calories) on the other two days.  The idea behind this is that a more prolonged period without food discourages fat storage, and allows our body to switch its metabolism over to burn our stored fat supplies.

A recent study in mice (1) seems to support this idea. In this study, two groups of mice were allowed to eat as much as they wanted. One group had food available at all times, while the other group only had food available for a 12-hour period each day. The group with the more restrictive time ate about the same number of calories as the other group, and yet maintained a healthy body weight, while the unrestricted group became obese.  The time-restricted mice were even able to reverse obesity and prevent type-2 diabetes.  Cholesterol balance improved within two weeks, and blood sugar control improved within a few days.

A related study (2) showed how this intermittent fasting can change the composition of the gut microbiome.  A healthier blend of friendly intestinal bacteria leads to leaner body weight.

It's too soon to translate these results directly to humans, but there have been some small human studies that point to the benefits of this approach.  One study found that intermittent fasting led to the same amount of fat loss as traditional calorie-restricted diets, but preserved much more healthy lean tissue. (3)

In a way, all of this seems to hearken back to traditional Chinese and Ayurvedic medicine: these systems used more poetic language to recommend against eating late into the evening or at night.  Whatever the reasoning, the outcome seems to be the same -- better health when we pay more attention to eating at the right time of day.

Listen to an interview with one of the researchers:  You Are 'When' You Eat 

1.  Amandine Chaix, Amir Zarrinpar, Phuong Miu, Satchidananda Panda.  Time-Restricted Feeding Is a Preventative and Therapeutic Intervention against Diverse Nutritional Challenges.  DOI: http://dx.doi.org/10.1016/j.cmet.2014.11.001

2.  Amir Zarrinpar, Amandine Chaix, Shibu Yooseph, Satchidananda Panda.  Diet and Feeding Pattern Affect the Diurnal Dynamics of the Gut Microbiome.  DOI: http://dx.doi.org/10.1016/j.cmet.2014.11.008

3.  Intermittent fasting vs daily calorie restriction for type 2 diabetes prevention: a review of human findings.  Transl Res. 2014 Oct;164(4):302-11. doi: 10.1016/j.trsl.2014.05.013. Epub 2014 Jun 12.

Gamification

Healthy lifestyle habits:  we know we should do them, but sometimes, it just seems like work.  Yes, Dr. Peters, I know that a Mediterranean diet and exercise will decrease my risk of dying, but it's just one more thing to add to the daily to-do list.  A phenomenon has popped up in recent years that makes it just a little less onerous to keep our minds and bodies fit:  gamification.  Gamification can be defined as transforming real-world tasks into games, to make them more fun and engaging.

There are obvious examples that help with exercise motivation:  console games such as Wii Fit, the Just Dance series, Your Shape, and others that provide entertainment, scores to improve upon, and even goal setting.  My latest favorite game to help with physical activity takes this a step further -- out of the living room and into the larger world.  Ingress is a free sci-fi themed game that uses your smartphone's GPS to interact with locations in the real world.  Notable landmarks and outdoor public art are "exotic matter portals" that can be hacked.  I have found that this makes walking not a chore, but something that I just want to do a little more of, to reach the next portal.


Maybe points in a game are not enough to keep you going -- okay, how about cold, hard cash?  AchieveMint does just that, rewarding you with money for engaging in healthy lifestyle habits.  MindBloom is a "life improvement" app that helps with planning and keeping on track with diet, exercise, and even mental and emotional health.

We can keep our brains fit with games, also.  Attention span may be improved with rhythmic activities like the stepper game in Wii  Fit.  We strengthen our memory "muscles" by learning new things, such as foreign languages.  I have been working on French, Spanish, and German with a free web-based service called DuoLingo.  Earning points and keeping up an unbroken streak of practice days really drives me to stick with it.  Lumosity offers free and paid options to challenge and stretch many different brain abilities.

People are very good at sticking with games they enjoy (just think of all the wasted hours with Candy Crush Saga!).  So instead of choosing a couch magnet, make your next game one that adds years and quality to your life.

Please note:  I have no financial relationship with any of the games mentioned.  I do request that if you play Ingress, you join the Enlightenment faction, just because you will be so much cooler.

Healthy Food? Blech!

One of the main impediments that many people cite in avoiding healthy foods is taste.  When the average American is faced with the choice between a Frappuccino and a kale salad, it's no mystery which one will be chosen.  Our brains are hard-wired to seek out fats, sugar, and salt for survival -- but with the modern food-industrial complex, these once-scarce resources are available in virtually endless supply in our country.  I've gone into a lot of detail previously on what constitutes a healthy diet:  Mediterranean-style eating, high in fiber, low in refined flours and sugars, with moderate amounts of healthy fats (such as olive oil and nuts) and lean proteins (such as legumes and fish).  So how do we get over the hurdle of transitioning to this style of eating... and more importantly, how do we adopt this on a permanent basis?  It can be easy to stick with any "diet" for a few weeks, but long-term health requires a lifestyle change.

Kids.  As a parent, I know how challenging it can be to introduce healthy foods in the face of the "beige diet:" chicken nuggets, corn, bananas, pizza, cereal, cookies.  The key here is persistence and repetition:  Food experts tell us that it can take 10-12 times of encountering a new food before young children will accept it.  Just keep putting that broccoli on their plates, and requiring at least one "thank-you bite."  Eventually, they'll get used to it.

Adults.  Are we just "in the habit" of eating unhealthy foods -- or are we actually addicted to them? While this term is controversial, there have been studies that show the same brain areas light up on functional MRI in response to refined sugar as they do for cocaine (1).  In 2007, a rat study found that the animals actually preferred the sweet stuff over cocaine when given a choice (2).

So how do we break this addiction?  Mark Hyman, MD, recommends approaching it the same way you would with any other addiction:  go cold turkey.  In this case, it means absolutely no sugar or refined grain products for at least 10 days.  This gives a chance for the taste buds and (more importantly) the reward centers of the brain to hit the reset button, so that we are not so sensitized to the sweet stuff.  We can then actually start tasting other foods, and they taste better by comparison.

A small pilot study by researchers at Harvard and Tufts Universities (3) used functional MRI to measure brain reward response in overweight and obese individuals before and after a structured low-glycemic index diet.  This plan, called the iDiet (or "instinct diet"), overcomes the natural tendency toward sweets by substituting healthier ingredients in familiar dishes, encouraging more frequent eating of healthy meals to avoid hunger, and involving interpersonal support.  After 24 weeks, the reward centers of the brain showed less reponse to high-calorie foods, and more response to low-calorie foods.  In plain English, this proves that on a neurological level, the brain can be rewired to enjoy healthier foods.

So it takes some effort, but it shows that old habits can be changed.  Dr. Hyman emphasizes that willpower is not the issue here:  the combination of our neurobiology with what K. D. Brownell (4) calls a "toxic food environment" creates a trap for us.  A structured kick-start might be just what we need to turn over a healthier leaf.

1. Avena N et al.  Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake.  Neurosci Biobehav Rev. 2008; 32(1): 20–39.  Published online May 18, 2007. doi:  10.1016/j.neubiorev.2007.04.019
2. Lenoir M, Serre F, Cantin L, Ahmed SH (2007) Intense Sweetness Surpasses Cocaine Reward. PLoS ONE 2(8): e698. doi:10.1371/journal.pone.0000698.
3. Pilot randomized trial demonstrating reversal of obesity-related abnormalities in reward system responsivity to food cues with a behavioral intervention.  Nutrition & Diabetes (2014) 4, e129; doi:10.1038/nutd.2014.26.  Published online 1 September 2014.
4. Brownell KD, et. al. Personal responsibility and obesity: a constructive approach to a controversial issue. Health Aff (Millwood). 2010 Mar-Apr;29(3):379-87

The Skinny on Fat

In the 1970s and 80s, fat was the bad boy of nutrition.  Since then, research has reminded us of so many of the “forgotten” good things about fat -- from the benefits of omega-3 fatty acids, to absorbing our fat-soluble vitamins and beyond.  As research goes on, more facts come to light to dispel our fears of this nutrient.

A few months ago, I reported that a Mediterranean diet rich in olive oil and nuts decreases the risk of cardiovascular disease by 30% compared to a low-fat diet.  Further analysis (1) of the data from this study (the PREDIMED study from Spain) found that the monounsaturated fat-rich Mediterranean diet also decreased diabetes risk by a third.  This is huge:  cardiovascular disease and diabetes are two of the biggest causes of death and morbidity in this country.  Focusing on low glycemic index foods like whole grains, legumes, fruits, and vegetables, as well as losing our fear of healthy fats like extra-virgin olive oil, can spell out huge health benefits.

Furthermore, a meta-analysis (a study of studies) published in the American Journal of Clinical Nutrition in 2010 (2) tore down one of the most sacred cows of nutrition and health research:  the "evil" of saturated fat.  The authors found no association of saturated fat intake with cardiovascular disease or stroke in the best-designed nutritional studies available to date.  This is mind-boggling, since everyone "knows" that chomping on a cheeseburger will instantly make your arteries clog up.  The jury is still out. but it appears that the ratio of unsaturated fat (from sources like olive oil, fish oil, or nuts) to saturated fat is more important than the absolute amount of saturated fat.  Translated into English, this means that at least half of your dietary fat should come from these healthier sources.  One word of caution, though, is that omega-6-rich fats such as vegetable oil might actually be bad for the heart.

As we sort through all of this evidence. it looks like the best recommendations we have to date are:

• Overall, a low-fat diet is not healthier for most people.
• Balance saturated fat intake (meat, dairy, coconut oil) with healthier fats (olive oil, nuts, avocados).
• Use vegetable oils sparingly (canola, corn, peanut oil).
• Do all of this in the context of a varied, fiber-rich, low glycemic index eating pattern, such as the Mediterranean Diet.

1.  Ann Intern Med. 2014;160(1):1-10-10. doi:10.7326/M13-1725
2.  Am J Clin Nutr 2010;91:535–46.

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

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. 

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

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.

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.