Are You Sitting Down? Think Again...

Imagine two co-workers:  one slim, the type who can seem to eat anything without gaining a pound -- and therefore does not feel the need to exercise; the other one overweight, but who works out regularly.  In spite of your latter colleague's efforts, he has found it very difficult to lose weight.  Which one is at greater risk for health problems down the road?

The answer is not so clear-cut, since both obesity and physical inactivity have been linked to chronic diseases:  cardiovascular disease, diabetes, osteoarthritis, etc.  If you were forced to choose, though, it appears more and more that keeping physically active is the more important variable for decreasing health risks.

• Australian researchers (1) recently found that being sedentary accounts for about half the risk for cardiovascular disease in middle-age women -- more than obesity, high blood pressure, or even smoking.
• Recent studies in BMJ (the British Medical Journal) found that for older adults, light daily physical activity decreased the disability associated with knee arthritis (2), and poor physical fitness nearly quadrupled the risk for all-cause mortality (death by any cause) (3).
• While many studies have focused on light-to-moderate exercise, a new study in the Journal of the American College of Cardiology looked at something a bit higher impact -- namely running -- and found that running, even as little as 5-10 minutes per day, decreased cardiovascular and all-cause mortality risk by 30-50%. (4)
• Author Nilofer Merchant has compiled the research, and calls sitting the "new smoking" -- the big public health scourge that needs to be addressed in the 21st century.

What can you do today to incorporate more physical activity?

• Park a little further from your destination
• Walk the dog a little further each morning
• Jog in place during each commercial break on TV

Our bodies are designed for exercise throughout life -- so keep it moving!

1. Br J Sports Med. Published online May 8, 2014.
2. Relation of physical activity time to incident disability in community dwelling adults with or at risk of knee arthritis: prospective cohort study.  BMJ 2014;348:g2472
3. Physical capability in mid-life and survival over 13 years of follow-up: British birth cohort study.  BMJ 2014;348:g2219
4. Leisure-Time Running Reduces All-Cause and Cardiovascular Mortality Risk.  J Am Coll Cardiol. 2014;64(5):472-481. doi:10.1016/j.jacc.2014.04.058

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.

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.

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).

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. 

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