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.

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. 

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.

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

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.

Is Vitamin D Good for the Heart or Not?

Based on much recent research linking low levels of vitamin D to increased risk of heart disease, this is something I measure in all of my older patients.  If low, supplementation is simple, cheap, and can effectively raise those levels back up.  This is especially important at this time of year, since the sun is not strong enough to produce any vitamin D from skin exposure at our latitude.

A recent study in the Journal of Clinical Endocrinology & Metabolism (1) looked at the question of whether or not supplementing with vitamin D can change cardiovascular risk.  This was one of the first actual placebo-controlled clinical trials to examine the question.  Half the participants got vitamin D3 (a good quality form of vitamin D), and the other half got placebo.  At the end of the study, they examined cardiovascular risk markers, such as blood cholesterol, blood pressure, and C-reactive protein, and found no significant difference between the groups.  The conclusion?  Quoting from the New York Times:

“The study actually shows that vitamin D does not protect you against heart disease,” said Helen M. Macdonald, a senior lecturer at the University of Aberdeen in Scotland, who led the study. “That’s not what people want to hear, but it’s true.”

Now hold on a minute.  The researchers are making a huge assumption:  that the risk markers of cholesterol, C-reactive protein, etc., are synonymous with heart disease.  The thinking is that if something (in this case vitamin D) does not affect those traditional risk markers directly, there is no impact on heart disease.   However, it is well known that a significant percentage of heart disease and heart attacks occur in people with normal cholesterol levels and blood pressure.  Perhaps vitamin D is an independent risk factor -- that is, it could protect against heart disease without changing those other parameters.

The way to  really tell this for sure experimentally would be to use actual cases of heart disease as the end point of vitamin D supplementation.  This study was a good first step, but the error in logic on the part of the researchers is glaring.  In the meantime, I'll keep checking blood levels of vitamin D on my patients over age 40 as part of an overall cardiovascular risk assessment, using the naturopathic principle of "Treat the whole person."

1.  Vitamin D₃ Supplementation Has No Effect on Conventional Cardiovascular Risk Factors: A Parallel-Group, Double-Blind, Placebo-Controlled RCT.  Published online before printAugust 3, 2012, doi:10.1210/jc.2012-2126
The Journal of Clinical Endocrinology & Metabolism, October 1, 2012 vol. 97 no. 103557-3568

Top 5 "Myths" in Natural Medicine

As a doctor of naturopathic medicine, I have years of experience and training to respect the vis medicatrix naturae, or healing power of nature.  This is foundational to our approach to health.  I also have a background in science, and know that it is important to examine natural methods of health care to see if they are valid and effective.

That is why (though it might be dangerous to step on some toes) I like to clarify common misperceptions:  My goal is to help patients be as healthy as possible, not to be wedded to a particular idea.  Therefore, over the next few articles, I will present five common myths I often encounter, in no particular order.

Myth #1: Policosanol is a good alternative to cholesterol-lowering medication.
Policosanol is an extract of the sugar cane plant that made big news about ten years ago, with studies showing it was very effective at lowering blood cholesterol levels (1).  The nutritional supplement industry responded with a deluge of policosanol products.  However, much of that early research was conducted in Cuba, the source of the sugar cane--the raw material for policosanol production.  Follow-up studies conducted on larger populations, showed little to no clinically significant cholesterol-lowering effects of policosanol (2, 3).  Even though this well-designed research was published in 2006, policosanol sales continue to this day.  More recent research from 2011 (4) found that even a form of policosanol modified to make it better absorbed from the gastrointestinal tract failed to make a significant dent in cholesterol levels.  Some recent studies showing benefits used policosanol in combination with red yeast rice and berberine, two natural compounds that have been proven time and again to be effective in lowering cholesterol.  It's highly likely in these studies that the policosanol could have been left out, without affecting the results.

With all this evidence against policosanol, why are sales still so brisk today?  Well, in the midst of bashing the evil of Big Pharma companies, we sometimes forget that supplement companies are businesses, too, driven by market forces.  As long as there's a demand for policosanol (based on those biased studies from 10-15 years ago), they'll keep selling it.  Sorry, folks--supplement companies are not selfless crusaders for health; they're driven by the profit motive.  It's the American way.

I stopped recommending policosanol in 2006, in favor of much more effective treatments.  I also like to remind patients that high cholesterol is not a disease; it's a risk factor for cardiovascular disease (CVD).  I put the emphasis on lifestyle factors for CVD prevention, and look at modifying other risk factors too (such as high-sensitivity C-reactive protein and blood levels of vitamin D).

Next Time:  Cinnamon for blood sugar control

1.  Policosanol: a new treatment for cardiovascular disease?  Altern Med Rev. 2002 Jun;7(3):203-17.

2.  Effect of policosanol on lipid levels among patients with hypercholesterolemia or combined hyperlipidemia: a randomized controlled trial.  JAMA. 2006 May 17;295(19):2262-9.

3.  Comparative lipid-lowering effects of policosanol and atorvastatin: a randomized, parallel, double-blind, placebo-controlled trial.  Am Heart J. 2006 Nov;152(5):982.e1-5.

4.  Modified-policosanol does not reduce plasma lipoproteins in hyperlipidemic patients when used alone or in combination with statin therapy.  Lipids. 2011 Oct;46(10):923-9. Epub 2011 Jul 8.

More Good News for Chocolate

Ah, how times change.  Just a few years ago, chocolate was undoubtedly in the junk food category, yet a flurry of recent research has confirmed its benefits to cardiovascular health.  The latest is a study from Sweden published last month (1) that showed that higher chocolate consumption cut men's stroke risk by 17%.  And it didn't need to be much -- just an average of about 2 ounces per week, compared to non-consumers.  The key seems to be the flavonoids in cocoa:  compounds that have antioxidant activity, and improve endothelial function (the inner lining of large blood vessels).

Prior research showed cardiovascular benefits from dark chocolate, which have a higher cocoa content (55-90%) than milk chocolate (30%).  So for maximal benefit, reach for the dark chocolate.  This also avoids the high amounts of sugar and saturated fat in milk chocolate, which can contribute to obesity and metabolic syndrome.

It might take time to get used to the less sweet taste of dark chocolate, but with small amounts (1/2 - 1 ounce per day), your palate will adjust.  My advice?  Become a chocolate snob.  Buy good quality dark chocolate, and really focus in and enjoy that little tidbit, rather than cramming down a whole bar of cheap milk chocolate.


1.  Chocolate consumption and risk of stroke:  A prospective cohort of men and meta-analysis.  Neurology. 2012;79:1223-1229. Published online August 29, 2012.