Heart Health Archives - Page 3 of 4 - Health Tips From The Professor

Which Supplements Are Good For Your Heart?

February 7, 2023 by Dr. Steve Chaney

How Should You Interpret This Study?

Author: Dr. Stephen Chaney

February is Heart Health month. So, it is fitting that we ask, “What is the status of heart health in this country?” The American Heart Association just published an update of heart health statistics through 2019 (CW Tsao et al, Circulation, 145: e153-e639, 2022). And the statistics aren’t encouraging. [Note: The American Heart Association only reported statistics through 2019 because the COVID-19 pandemic significantly skewed the statistics in 2020 and 2021].

The Good News is that between 2009 and 2019:

All heart disease deaths have decreased by 25%.
Heart attack deaths have decreased by 6.6%.
Stroke deaths have decreased by 6%.

The Bad News is that:

Heart disease is still the leading cause of death in this country.
Someone dies from a heart attack every 40 seconds.
Someone dies from a stroke every 3 minutes.

Diet, exercise, and weight control play a major role in reducing the risk of heart disease. Best of all, they have no side effects. They represent a risk-free approach that each of us can control.

But is there something else? Could supplements play a role? Are supplements hype or hope for a healthy heart?

All the Dr. Strangeloves in the nutrition space have their favorite heart health supplements. They claim their supplements will single-handedly abolish heart disease (and help you leap tall buildings in a single bound).

On the other hand, many doctors will tell you these supplements are a waste of money. They don’t work. They just drain your wallet.

It’s so confusing. Who should you believe? Fortunately, a recent study (P An et al, Journal of the American College of Cardiology, 80: 2269-2285, 2022) has separated the hype from the hope and tells us which “heart-healthy” supplements work, and which don’t.

How Was This Study Done?

This was a major clinical study carried out by researchers from the China Agricultural University and Brown University in the US. It was a meta-analysis, which means it combined the data from many published clinical trials.

The investigators searched three major databases of clinical trials to identify:

884 randomized, placebo-controlled clinical studies…

Of 27 types of micronutrients…

With a total of 883,627 patients…

Looking at the effectiveness of micronutrient supplementation lasting an average of 3 years on either…

- Cardiovascular risk factors like blood pressure, total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides…or…

- Cardiovascular outcomes such as coronary heart disease (CHD), heart attacks, strokes, and deaths due to cardiovascular disease (CVD) and all causes.

[Note: Coronary heart disease (CHD) refers to build up of plaque in the coronary arteries (the arteries leading to the heart). It is often referred to as heart disease and can lead to heart attacks (myocardial infarction). Cardiovascular disease (CVD) is a more inclusive term that includes coronary heart disease, stroke, congenital heart defects, and peripheral artery disease.]

The investigators also included an analysis of the quality of the data in each of the clinical studies and rated the evidence of each of their findings as high quality, moderate quality, or low quality.

Which Supplements Are Good For Your Heart?

The top 3 heart-healthy supplements in this study were:

Omega-3 Fatty Acids:

Increased HDL cholesterol and decreased triglycerides, both favorable risk factors for heart health.
Deceased risk of heart attacks by 15%, all CHD events by 14%, and CVD deaths by 7% (see definitions of CHD and CVD above).
The median dose of omega-3 fatty acids in these studies was 1.8 g/day.
The evidence was moderate quality for all these findings.

Folic Acid:

Decreased LDL cholesterol (moderate quality evidence) and decreased blood pressure and total cholesterol (low quality evidence).
Decreased stroke risk by 16% (moderate quality evidence).

Coenzyme Q10:

Decreased triglycerides (high quality evidence) and reduced blood pressure (low quality evidence).
Decreased the risk of all-cause mortality by 32% (moderate quality evidence).
These studies were performed with patients diagnosed with heart failure. Coenzyme Q10 is often recommended for these patients, so the studies were likely performed to test the efficacy of this treatment.

There were three micronutrients (vitamin C, vitamin E, and vitamin D) that did not appear to affect heart disease outcomes.

Finally, as reported in previous studies, β-carotene increased the risk of stroke, CVD mortality, and all-cause mortality.

In terms of the question I asked at the beginning of this article, this study concluded that:

Omega-3, folic acid, and coenzyme Q10 supplements represent hope for a healthy heart.
Vitamin C, vitamin E, and vitamin D supplements represent hype for a healthy heart.
β-carotene supplements represent danger for a healthy heart.

But these conclusions just scratch the surface. To put them into perspective we need to dig a bit deeper.

How Should You Interpret This Study?

In evaluating the significance of these findings there are two things to keep in mind.

#1: This study is a meta-analysis and meta-analyses have both strengths and weaknesses.

The strength of meta-analyses is that by combining multiple clinical studies they can end up with a database containing 100s of thousands of subjects. This allows them to do two things:

It allows the meta-analysis to detect statistically significant effects that might be too small to detect in an individual study.
It allows the meta-analysis to detect the average effect of all the clinical studies it includes.

The weakness of meta-analyses is that the design of individual studies included in the analysis varies greatly. The individual studies vary in things like dose, duration, type of subjects included in the study, and much more.

This is why this study rated most of their conclusions as backed by moderate- or low-quality evidence. [Note: The fact that the authors evaluated the quality of evidence is a strength of this study. Most meta-analyses just report their conclusions without telling you how strong the evidence behind those conclusions is.]

#2: Most clinical studies of supplements (including those included in this meta-analysis) have two significant weaknesses.

Most studies do not measure the nutritional status of their subjects prior to adding the supplement. If their nutritional status for a particular nutrient was already optimal, there is no reason to expect more of that nutrient to provide any benefit.
Most studies measure the effect of a supplement on a cross-section of the population without asking who would be most likely to benefit.

You would almost never design a clinical study that way if you were evaluating the effectiveness of a potential drug. So, why would you design clinical studies of supplements that way?

With these considerations in mind, let me provide some perspective on the conclusions of this study.

Coenzyme Q10:

This meta-analysis found that coenzyme Q10 significantly reduced all-cause mortality in patients with heart failure. This is consistent with multiple clinical studies and a recent Cochrane Collaboration review.

Does coenzyme Q10 have any heart health benefits for people without congestive heart failure? There is no direct evidence that it does, but let me offer an analogy with statin drugs.

Statin drugs are very effective at reducing heart attacks in high-risk patients. But they have no detectable effect on heart attacks in low-risk patients. However, this has not stopped the medical profession from recommending statins for millions of low-risk patients. The rationale is that if they are so clearly beneficial in high-risk patients, they are “probably” beneficial in low-risk patients.

I would argue a similar rationale should apply to supplements like coenzyme Q10.

Omega-3s:

This study found that omega-3 reduced both heart attacks and the risk of dying from heart disease. Most previous meta-analyses of omega-3s and heart disease have come to the same conclusion. However, some meta-analyses have failed to find any heart health benefits of omega-3s. Unfortunately, this has allowed both proponents and opponents of omega-3 use for heart health to quote studies supporting their viewpoint.

However, there is one meta-analysis that stands out from all the others. A group of 17 scientists from across the globe collaborated in developing a “best practices” experimental design protocol for assessing the effect of omega-3 supplementation on heart health. They conducted their clinical studies independently, and when their data (from 42,000 subjects) were pooled, the results showed that omega-3 supplementation decreased:

Premature death from all causes by 16%.
Premature death from heart disease by 19%.
Premature death from cancer by 15%.
Premature death from causes other than heart disease and cancer by 18%.

This study eliminates the limitations of previous meta-analyses. That makes it much stronger than the other meta-analyses. And these results are consistent with the current meta-analysis.

Omega-3s have long been recognized as essential nutrients. It is past time to set Daily Value (DV) recommendations for omega-3s. Based on the recommendations of other experts in the field, I think the DV should be set at 500-1,000 mg/day. I take more than that, but this would represent a good minimum recommendation for heart health.

Folic acid:

As with omega-3s, this meta-analysis reported a positive effect of folic acid on heart health. But many other studies have come up empty. Why is that?

It may be because, between food fortification and multivitamin use, many Americans already have sufficient blood levels of folic acid. For example, one study reported that 70% of the subjects in their study had optimal levels of folates in their blood. And that study also reported:

Subjects with adequate levels of folates in their blood received no additional benefit from folic acid supplementation.
However, for subjects with inadequate blood folate levels, folic acid supplementation decreased their risk of heart disease by ~15%.

We see this pattern over and over in supplement studies. Supplement opponents interpret these studies as showing that supplements are worthless. But a better interpretation is that supplements benefit those who need them.

The problem is that we don’t know our blood levels of essential nutrients. We don’t know which nutrients we need, and which we don’t. That’s why I like to think of supplements as “insurance” against the effects of an imperfect diet.

Vitamins E and D:

The situation with vitamins E and D is similar. This meta-analysis found no heart health benefit of either vitamin E or D. That is because the clinical studies included in the meta-analysis asked whether vitamin E or vitamin D improved heart health for everyone in the study.

Previous studies focusing on patients with low blood levels of these nutrients and/or at high risk of heart disease have shown some benefits of both vitamins at reducing heart disease risk.

So, for folic acid, vitamin E, and vitamin D (and possibly vitamin C) the take-home message should be:

Ignore all the Dr. Strangeloves telling you that these vitamins are “magic bullets” that will dramatically reduce your risk of heart disease.
Ignore the naysayers who tell you they are worthless.
Use supplementation wisely to make sure you have the recommended intake of these and other essential nutrients.

β-carotene:

This meta-analysis reported that β-carotene increased the risk of heart disease. This is not a new finding. Multiple previous studies have come to the same conclusion.

And we know why this is. There are many naturally occurring carotenoids, and they each have unique heart health benefits. A high dose β-carotene supplement interferes with the absorption of the other carotenoids. You are creating a deficiency of other heart-healthy carotenoids.

If you are not getting lots of colorful fruits and vegetables from your diet, my recommendation is to choose a supplement with all the naturally occurring carotenoids in balance – not a pure β-carotene supplement.

The Bottom Line

The Dr. Strangeloves in the nutrition space all have their favorite heart health supplements. They claim their supplements will single-handedly abolish heart disease (and help you leap tall buildings in a single bound).

On the other hand, many doctors will tell you these supplements are a waste of money. They don’t work. They just drain your wallet.

It’s so confusing. Who should you believe? Fortunately, a recent study has separated the hype from the hope and tells us which “heart-healthy” supplements work, and which don’t.

This study was a meta-analysis of 884 clinical studies with 883,627 participants. It reported:

Omega-3 supplementation deceased risk of heart attacks by 15% and all cardiovascular deaths by 7%.
Folic acid supplementation decreased stroke risk by 16%.
Coenzyme Q10 supplementation decreased the risk of all-cause mortality in patients with heart failure by 32%.
Vitamin C, vitamin E, vitamin D did not appear to affect heart disease outcomes.
β-carotene increased the risk of stroke, CVD mortality, and all-cause mortality.

For more details on this study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Does Magnesium Protect Your Heart?

October 25, 2022 by Dr. Steve Chaney

Do You Need A Magnesium Supplement?

Author: Dr. Stephen Chaney

Getting an adequate amount magnesium from our diet should not be a problem. Magnesium is found in a wide variety of foods with the best sources being legumes (beans), nuts, seeds, whole grains, green leafy vegetables, and dairy foods.

The problem is:

None of these foods contain enough magnesium by themselves to provide the RDA (420 mg/day for men and 320 mg/day for women) for magnesium. We need to consume a variety of these foods every day – something most Americans aren’t doing.

These foods are decent sources of magnesium only in their unprocessed form. And most Americans consume more highly processed foods than whole, unprocessed foods.

Two to three servings of dairy provide a decent amount of magnesium, but many Americans are cutting back on dairy. And plant-based dairy substitutes often provide much less magnesium than the dairy food they replace.

Finally, green leafy vegetables (iceberg lettuce doesn’t count) don’t make it into the American menu as often as they should.

As a result, recent studies find that at least 50% of Americans are not getting enough magnesium in their diet. In fact, the average magnesium intake in this country is 268 mg/day for men and 234 mg/day for women. And the figures are not very different in other developed countries.

Does it matter? Recent studies have shown that an adequate intake of dietary magnesium is associated with lower risks of cardiovascular diseases (CVD) and all-cause mortality. This may be because of the of role of magnesium in supporting heart muscle contraction, normal heart rhythm, and blood pressure regulation. Adequate magnesium intake is also associated with lower risk of type 2 diabetes.

But what if you have already had a heart attack? Is it too late for magnesium to make a difference? A recent study (I Evers et al, Frontiers in Cardiovascular Medicine, August 12, 2022) was designed to answer this question.

The authors examined the effect of magnesium intake on cardiovascular disease (CVD) mortality, all-cause mortality, and coronary heart disease (CHD) mortality in patients who had experienced a recent heart attack.

[Note: CHD is defined as heart disease due to clogged coronary arteries, such as a heart attack. CVD includes CHD plus diseases caused by other clogged blood vessels, such as strokes and peripheral artery disease].

How Was The Study Done?

The authors used data from a previous study that had enrolled 4,365 Dutch patients aged 60-80 (average age = 69) who had experienced a heart attack within approximately 4 years prior to enrollment and followed them for an average of 12.4 years. All patients were receiving standard post-heart attack drug therapy.

The characteristics of the patients enrolled in the study were as follows:

Male 79%, female 21%
Average magnesium intake = 302 mg/day
Percent magnesium deficient: 72% of men and 67% of women
Percent taking magnesium supplements = 5.4%
Percent on drugs to lower blood pressure = 90%
Percent on statins = 86%
Percent on diuretics = 24%

Upon entry into the study the patients were asked to fill out a 203-item food frequency questionnaire reflecting their dietary intake over the past month. Trained dietitians reviewed the questionnaires and phoned the participants to clarify any unclear or missing items. The questionnaires were linked to the 2006 Dutch Food Composition Database to calculate magnesium intake and other aspects of their diets.

The patients were divided into 3 groups based on their energy adjusted magnesium intakes and those in the highest third (>322 mg/day) were compared to those in the lowest third (<238 mg/day) with respect to cardiovascular disease (CVD), all-cause mortality, and coronary heart disease (CHD) mortality.

The comparisons were statically adjusted for fiber intake (most magnesium-rich foods are also high fiber foods), diuretic use (diuretics reduce magnesium levels in the blood), age, sex, smoking, alcohol use, physical activity, obesity, education level, caloric intake, calcium, vitamin D, sodium from foods, potassium, heme iron, vitamin C, beta-carotenoids, polyunsaturated fatty acids, saturated fatty acids, overall diet quality based on the Dutch Dietary Guidelines, systolic blood pressure, kidney function, and diabetes. In other words, the data were adjusted for every conceivable variable that could have influenced the outcome.

Does Magnesium Protect Your Heart?

When those with the highest magnesium intake (>322 mg/day) were compared to those with the lowest intake (<283 mg/day):

Cardiovascular disease (CVD) mortality was reduced by 28%.

All-cause mortality was reduced by 22%.

Coronary heart disease (CHD) mortality was reduced by 16%, but that reduction was not statistically significant.

They then looked at the effect of some variables that might affect CVD risk on the results.

Diabetes, kidney function, iron intake, smoking, alcohol use, blood pressure, most dietary components and overall diet quality had no effect on the results.

The results were also not affected when patients using a magnesium supplement were excluded from the analysis. This suggests the effect of magnesium from diet and supplementation is similar.

However, diuretic use had a significant effect on the results.

- For patients using diuretics, high magnesium intake versus low magnesium intake reduced CVD mortality by 45%.

How Much Magnesium Do You Need?

You may have noticed that the difference between the highest magnesium intake group and the lowest intake group was, on average, only 39 mg/day. So, the authors also used a statistical approach that utilized data from each individual patient to produce a graph of magnesium intake versus risk of CVD, total, and CHD mortality. For all 3 end points the graphs showed an inverse, linear relationship between magnesium and mortality.

From this, the authors were able to calculate the effect of each 100mg/day increase in magnesium intake on mortality risk. Each 100mg/day of added magnesium reduced the risk of:

CVD mortality by 38%.

All-cause mortality by 30%.

CHD mortality by 33%, and these results were borderline significant.

The inverse relationship between magnesium intake was observed at intakes ranging from around 200 mg/day to around 450 mg/day, which represented the range of dietary magnesium intake in this Dutch population group.

This study did not define an upper limit to the beneficial effect of magnesium intake because the graphs had not plateaued at 450 mg/day, suggesting that higher magnesium intakes might give even better results.

The authors concluded, “We observed a strong, linear inverse association of dietary magnesium with CVD and all-cause mortality after a heart attack, which was most pronounced in patients who used diuretics. Our findings emphasize the importance of an adequate magnesium intake in CVD patients, on top of cardiovascular drug treatment.”

I might add that this is the first study to look at the effect of magnesium on long-term survival after a heart attack.

Do You Need A Magnesium Supplement?

As I said earlier, the best dietary sources of magnesium are beans, nuts, seeds, whole grains, green leafy vegetables, and dairy foods. And:

None of these foods contain enough magnesium by themselves to provide the RDA (420 mg/day for men and 320 mg/day for women) for magnesium.

These foods are decent sources of magnesium only in their unprocessed form.

When unprocessed, each of these foods provides 20 to 60 mg of magnesium per serving. If we use an average value of 40 mg/serving, you would need in the range of 8-10 servings/day of these foods in their unprocessed form to meet the RDA for magnesium.

You could get a more accurate estimate of the magnesium content of your diet using the “Magnesium Content of Selected Foods” table from the NIH Factsheet on Magnesium.

Now you are ready to ask yourself two questions:

Does my current diet provide the RDA for magnesium?

2. If not, am I willing to make the dietary changes needed to increase my magnesium levels to RDA levels?

If your answer to both questions is no, you should probably consider a magnesium supplement. A supplement providing around 200 mg of magnesium should bring all but the worst diets up to the recommended magnesium intake.

The current study did not define an upper limit for the beneficial effect of magnesium on survival after a heart attack but suggested that intakes above 450 mg/day might be optimal.

I do not recommend megadoses of magnesium, but intakes from diet and supplementation that slightly exceed the RDA appear to be safe. In their Magnesium Factsheet, the NIH states, “Too much magnesium…does not pose a health risk in healthy individuals because the kidneys eliminate excess amounts in the urine.”

The only concern is that magnesium from supplements is absorbed much more rapidly than magnesium from foods, and this can cause gas, bloating, and diarrhea in some individuals. For this reason, I recommend a sustained release magnesium supplement, so the magnesium is absorbed more slowly.

Finally, we should not consider magnesium as a magic bullet. The current study statistically eliminated every known variable that might affect survival after a heart attack, so it could estimate the beneficial effects of magnesium alone.

However, survival after a heart attack will likely be much greater if diet, exercise, and body mass are also optimized.

The Bottom Line

Recent studies have shown that an adequate intake of dietary magnesium is associated with lower risks of cardiovascular diseases (CVD) and all-cause mortality.

But what if you have already had a heart attack? Is it too late for magnesium to make a difference? A recent study of heart attack patients in Holland was designed to answer this question.

When heart attack patients with the highest magnesium intake (>322 mg/day) were compared to those with the lowest intake (<283 mg/day):

Cardiovascular disease (CVD) mortality was reduced by 28%.

All-cause mortality was reduced by 22%.

Coronary heart disease (CHD) mortality was reduced by 16%, but that reduction was not statistically significant.

The authors went on to look at the inverse linear relationship between magnesium intake and mortality risk. They found that each 100mg/day of added magnesium reduced the risk of:

CVD mortality by 38%.

All-cause mortality by 30%.

CHD mortality by 33%, and these results were borderline significant.

The authors concluded, “We observed a strong, linear inverse association of dietary magnesium with CVD and all-cause mortality after a heart attack…Our findings emphasize the importance of an adequate magnesium intake in CVD patients…”

I might add that this is the first study to look at the effect of magnesium on long-term survival of patients who have suffered a heart attack.

For more details on this study and my discussion of whether you might benefit from a magnesium supplement, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

What Is The Truth About Low Carb Diets?

August 30, 2022 by Dr. Steve Chaney

Why Is The Cochrane Collaboration The Gold Standard?

Author: Dr. Stephen Chaney

Atkins, South Beach, Whole30, Low Carb, high Fat, Low Carb Paleo, and Keto. Low carb diets come in many forms. But they have these general characteristics:

They restrict carbohydrate intake to <40% of calories.

They restrict grains, cereals, legumes, and other carbohydrate foods such as dairy, fruits, and some vegetables.

They replace these foods with foods higher in fat and protein such as meats, eggs, cheese, butter, cream, and oils.

When recommended for weight loss, they generally restrict calories.

What about the science? Dr. Strangelove and his friends tell you that low carb diets are better for weight loss, blood sugar control, and are more heart healthy than other diets. But these claims are controversial.

Why is that? I have discussed this in previous issues of “Health Tips From The Professor”. Here is the short version.

Most studies on the benefits of low carb diets compare them with the typical American diet.

- The typical American diet is high in fat, sugar and refined flour, and highly processed foods. Anything is better than the typical American diet.

Most low carb diets are whole food diets.

- Any time you replace sodas and highly processed foods with whole foods you will lose weight and improve your health.

Most low carb diets are highly structured. There are rules for which foods to avoid, which foods to eat, and often additional rules to follow.

- Any highly structured diet causes you to focus on what you eat. When you do that, you lose weight. When you lose weight, your health parameters improve.

- As I have noted before, short term weight loss and improvement in health parameters are virtually identical for the very low carb keto diet and the very low-fat vegan diet.

With all this uncertainty you are probably wondering, “What is the truth about low carb diets?”

A recent study by the Cochrane Collaboration (CE Naude et al, Cochrane Database of Systematic Reviews, 28 January 2022) was designed to answer this question.

The Cochrane Collaboration is considered the gold standard of evidence-based medicine. To help you understand why this is, I will repeat a summary of how the Cochrane Collaboration approaches clinical studies that I shared two weeks ago.

Why Is The Cochrane Collaboration The Gold Standard?

Who you gonna call? It’s not Ghostbusters. It’s not Dr. Strangelove’s health blog. It’s a group called the Cochrane Collaboration.

The Cochrane Collaboration consists of 30,000 volunteer scientific experts from across the globe whose sole mission is to analyze the scientific literature and publish reviews of health claims so that health professionals, patients, and policy makers can make evidence-based choices about health interventions.

In one sense, Cochrane reviews are what is called a “meta-analysis”, in which data from numerous studies are grouped together so that a statistically significant conclusion can be reached. However, Cochrane Collaboration reviews differ from most meta-analyses found in the scientific literature in a very significant way.

Many published meta-analyses simply report “statistically significant” conclusions. However, statistics can be misleading. As Mark Twain said: “There are lies. There are damn lies. And then there are statistics”.

The Cochrane Collaboration also reports statistically significant conclusions from their meta-analyses. However, they carefully consider the quality of each individual study in their analysis. They look at possible sources of bias. They look at the design and size of the studies. Finally, they ask whether the conclusions are consistent from one study to the next. They clearly define the quality of evidence that backs up each of their conclusions as follows:

High-quality evidence. Further research is unlikely to change their conclusion. This is generally reserved for conclusions backed by multiple high-quality studies that have all come to the same conclusion. These are the recommendations that are most often adopted into medical practice.

Moderate-quality evidence. This conclusion is very likely to be true, but further research could have an impact on it.

Low-quality evidence. Further research is needed and could alter the conclusion. They are not judging whether the conclusion is true or false. They are simply saying more research is needed to reach a definite conclusion.

This is why their reviews are considered the gold standard of evidence-based medicine. If you are of a certain age, you may remember that TV commercial “When EF Hutton talks, people listen.” It is the same with the Cochrane Collaboration. When they talk, health professionals listen.

How Was The Study Done?

The authors of this Cochrane Collaboration Report included 61 published clinical trials that randomized participants into two groups.

The first group was put on a low carbohydrate diet (carbohydrates = <40% of calories).

The second group was put on a “normal carbohydrate” diet (carbohydrates = 45-65% of calories, as recommended by the USDA and most health authorities).

- The normal carbohydrate diet was matched with the low carbohydrate diet in terms of caloric restriction.

- Both diets were designed by dietitians and were generally whole food diets.

The participants in these studies:

Were middle-aged.
Were overweight or obese.
Did not have diagnosed heart disease or cancer.
May have diagnosed type-2 diabetes. Some studies selected participants that had diagnosed type 2 diabetes. Other studies excluded those patients.

The studies were of 3 types:

Short-term: Participants in these studies followed their assigned diets for 3 to <12 months.

Long-term: Participants in these studies followed their assigned diets for >12 to 24 months.

Short-term with maintenance: Participants in these studies followed their assigned diets for 3 months followed by a 9-month maintenance phase.

What Is The Truth About Low Carb Diets?

All the studies included in the Cochrane Collaboration’s meta-analysis randomly assigned overweight participants to a low carbohydrate diet (carbohydrates = <40% of calories) or to a “normal carbohydrate” diet (carbohydrates = 45-65% of calories) with the same degree of caloric restriction.

If low carb diets have any benefit in terms of weight loss, improving blood sugar control, or reducing heart disease risk, these are the kind of studies that are required to validate that claim.

This is what the Cochrane Collaboration’s meta-analysis showed.

When they analyzed studies done with overweight participants without type 2 diabetes:

Weight loss was not significantly different between low carb and normal carb diets in short-term studies (3 to <12 months), long-term studies (>12 to 24 months), and short-term studies followed by a 9-month maintenance period.

There was also no significant difference in the effect of low carb and normal carb diets on the reduction in diastolic blood pressure and LDL cholesterol.

Since diabetics have trouble controlling blood sugar, you might expect that type 2 diabetics would respond better to low carb diets. However, when they analyzed studies done with overweight participants who had type 2 diabetes:

Weight loss was also not significantly different on low carb and normal carb diets.

There was no significant difference in the effect of low carb and normal carb diets on the reduction in diastolic blood pressure, LDL cholesterol, and hemoglobin A1c, a measure of blood sugar control.

Of course, the reason Cochrane Collaboration analyses are so valuable is they also analyze the strength of the studies that were included in their analysis.

You may remember in my article two weeks ago, I reported on the Cochrane Collaboration’s report supporting the claim that omega-3 supplementation reduces pre-term births. In that report they said that the studies included in their analysis were high quality. Therefore, they said their report was definitive and no more studies were needed.

This analysis was different. The authors of this Cochrane Collaboration report said that the published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

What Does This Study Mean For You?

If you are a bit confused by the preceding section, I understand. That was a lot of information to take in. Let me give you the Cliff Notes version.

In short, this Cochrane Collaboration Report concluded:

Low carb diets (<40% of calories from carbohydrates) are no better than diets with normal carbohydrate content (45-65% of calories from carbohydrates) with respect to weight loss, reduction in heart disease risk factors, and blood sugar control. Dr. Strangelove has been misleading you again.

This finding is equally true for people with and without type 2 diabetes. This calls into question the claim that people with type 2 diabetes will do better on a low carb diet.

The published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

If you are thinking this study can’t be true because low carb diets work for you, that is because you are comparing low carb diets to your customary diet, probably the typical American diet.

Remember that any whole food diet that eliminates sodas and processed foods and restricts the foods you eat will cause you to lose weight. Whole food keto and vegan diets work equally well short-term compared to the typical American diet.

And any diet that allows you to lose weight improves heart health parameters and blood sugar control.

If you are thinking about the blogs, books, and videos you have seen extolling the virtues of low carb diets, remember that the Dr. Strangeloves of the world only select studies comparing low carb diets to the typical American diet to support their claims.

The studies included in this Cochrane Collaboration report randomly assigned participants to the low carb and normal carb diets and followed them for 3 to 24 months.

- Both diets were whole food diets designed by dietitians.

- Both diets reduced caloric intake to the same extent.

What about the claims that low carb diets are better for your long-term health? There are very few studies on that topic. Here are two:

At the 6.4-year mark a recent study reported that the group with the lowest carbohydrate intake had an increased risk of premature death – 32% for overall mortality, 50% for cardiovascular mortality, 51% for cerebrovascular mortality, and 36% for cancer mortality. I will analyze this study in a future issue of “Health Tips From The Professor”.

At the 20-year mark a series of studies reported that:

- Women consuming a meat-based low carb diet for 20 years gained just as much weight and had just as high risk of heart disease and diabetes as women consuming a high carbohydrate, low fat diet.

- However, women consuming a plant-based low carb diet for 20 years gained less weight and had reduced risk of developing heart disease and diabetes as women consuming a high carbohydrate, low fat diet.

My recommendation is to avoid low-carb diets. They have no short-term benefits when compared to a healthy diet that does not eliminate food groups. And they may be bad for you in the long run. Your best bet is a whole food diet that includes all food groups but eliminates sodas, sweets, and processed foods.

However, if you are committed to a low carb diet, my recommendation is to choose the low-carb version of the Mediterranean diet. It is likely to be healthy long term.

The Bottom Line

The Cochrane Collaboration, the gold standard of evidence-based medicine, recently issued a report that evaluated the claims made for low carb diets.

All the studies analyzed in the Cochrane Collaboration’s report randomly assigned overweight participants to a low carbohydrate diet (carbohydrates = <40% of calories) or to a “normal carbohydrate” diet (carbohydrates = 45-65% of calories) with the same degree of caloric restriction.

If low carb diets have any benefit in terms of weight loss, improving blood sugar control, or reducing heart disease risk, these are the kind of studies that are required to validate that claim.

The Cochrane Collaboration Report concluded:

Low carb diets (<40% of calories from carbohydrates) are no better than diets with normal carbohydrate content (45-65% of calories from carbohydrates) with respect to weight loss, reduction in heart disease risk factors, and blood sugar control.

This is equally true for people with and without type 2 diabetes.

The published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

My recommendation is to avoid low carb diets. They have no short-term benefits when compared to a healthy diet that does not eliminate food groups. And they may be bad for you in the long run. Your best bet is a whole food diet that includes all food groups but eliminates sodas, sweets, and processed foods.

However, if you are committed to a low carb diet, my recommendation is to choose the low carb version of the Mediterranean diet. It is likely to be healthy long term.

For more details on the study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Do Calcium Supplements Increase Deaths From Heart Valve Disease?

June 14, 2022 by Dr. Steve Chaney

What Did This Study Get Wrong?

Author: Dr. Stephen Chaney

“Killer calcium” is back. Once again, we are seeing headlines saying that calcium supplementation increases our risk of dying from heart disease. If you have seen these headlines, you are probably confused.

After all, there have been three major clinical studies looking at the effect of calcium supplementation on heart disease risk. These studies followed close to 100,000 Americans for 10-20 years. And none of the studies found any increase in the risk of developing or dying from heart disease for people taking calcium supplements. For more information on this topic, see an article from “Health Tips From the Professor”.

You are probably wondering, “What is going on? I thought this issue was settled”.

In the first place, this study did not look at heart disease in general, but on a very specific form of heart valve disease called aortic stenosis. Aortic stenosis is a narrowing of the heart valve leading to the aorta. And it is often associated with calcification of the heart valve.

The cause of aortic stenosis is complex, but it is associated with:

Chronic inflammation.
High cholesterol levels.
Tobacco use.
Dysregulation of calcium metabolism caused by things like elevated parathyroid levels and end-stage kidney disease.
Elevated blood levels of calcium and/or vitamin D.

Because of the role of calcium and vitamin D in aortic stenosis, the current study (N Kassis et al, Heart, Epub ahead of print, 1-9, 2022) was designed to ask whether calcium and vitamin D supplementation influenced the risk of dying from aortic stenosis.

How Was This Study Done?

The Cleveland Clinic scanned their Echocardiography Database for patients aged 60 years or more who had been diagnosed with mild to moderate aortic stenosis. 2,657 patients met these criteria (average age = 74, 58% men) and were followed for an average of 59 months in their database.

In terms of calcium and vitamin D supplementation:

49% did not supplement.

12.5% supplemented with vitamin D (dose not defined).

38.5% supplemented with calcium (500 – 2,000 mg/day) ± vitamin D.

The study looked at the correlation between vitamin D supplementation and calcium supplementation with:

Aortic valve replacement surgery.

All-cause mortality* with and without aortic valve replacement surgery.

Cardiovascular mortality* with and without aortic valve replacement surgery.

*Note: Since all the patients had aortic stenosis at the beginning of the study, both all-cause and cardiovascular mortality were primarily due to aortic stenosis.

Do Calcium Supplements Increase Deaths From Heart Valve Disease?

Before I describe the results of the study, there are two things you need to know:

Vitamin D supplementation did not have a significant effect on any outcome studied, so I will not mention vitamin D in the rest of this article.

In the calcium supplementing group, there were only a few people taking calcium supplements without vitamin D. However, their outcomes were the same as for people taking calcium + vitamin D supplements. Therefore, the authors discussed their results in terms of calcium supplementation, not calcium + vitamin D supplementation. I will do the same.

With those two things in mind, here is what the study found.

With respect to the need for aortic valve replacement surgery:

Calcium supplementation increased the need for surgery by 50%.

With respect to all-cause mortality:

Calcium supplementation increased the risk of death by 31%. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:

- Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.

- Those who did not receive aortic valve replacement surgery had a 38% increased risk of death.

With respect to cardiovascular mortality:

Calcium supplementation doubled the risk of death. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:

- Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.

- Those who did not receive aortic valve replacement surgery had a 205% increased risk of death.

The authors concluded, “Supplemental calcium … is associated with lower survival and greater AVR [aortic valve replacement surgery] in elderly patients with mild to moderate AV [aortic stenosis].”

What Did This Study Get Wrong?

Let me start by looking at the limitations of this study.

#1: This is a single study. It is a well-designed study, but it is only one study. And, as the authors acknowledge, previous studies have come down on both sides of this issue. Until we have more well-designed studies that come to the same conclusion, we cannot be confident this study is correct.

#2: The results of this study could have been significantly influenced by confounding variables.

For example:

End-stage kidney disease is associated with a dysregulation of calcium metabolism that can lead to aortic valve calcification. Patients in the calcium supplementation group had a 2-fold higher incidence of chronic kidney disease and a 10-fold higher incidence of kidney dialysis.

There were also significant differences in several diseases and drugs that influence the risk of developing aortic stenosis between the groups.

In the words of the authors, “Given the degree of clinical differences between the groups, there was a risk of residual confounding that may have impacted our findings; we attempted to mitigate this with our statistical model.”

However, as Mark Twain is quoted as saying, “There are lies. There are damn lies. And then there are statistics.”

That is a humorous way of saying we should not put too much faith in statistical manipulations of the data.

#3: They did not measure parathyroid levels. That is a serious omission because elevated parathyroid levels are a major driver of the type of dysfunctional calcium metabolism that could lead to calcification of the aortic valve.

#4: Serum calcium and vitamin D levels were slightly lower in the calcium supplementation group. This is unexpected because aortic stenosis is usually associated with higher serum calcium and vitamin D levels.

The authors speculated this might be due to transient increases in serum calcium levels following supplementation. This is possible for some calcium supplements, but not others.

Specifically, some calcium supplements are marketed on how quickly they get into the bloodstream. But those same supplements often do not provide all the nutrients needed for bone formation. There is always the possibility that excess calcium not used for bone formation might be deposited where we do not want it (such as in the aortic valve).

What Did This Study Get Right?

#1: It was a larger, longer lasting study than previous studies on the effect of calcium supplementation on aortic stenosis. Even though it has limitations, we shouldn’t discount it. It might just be correct.

#2: It doesn’t necessarily conflict with the earlier studies showing that calcium supplementation doesn’t increase cardiovascular disease risk. That’s because the design of these studies is very different.

The health of the people studied was very different.

- The earlier studies started with healthy adults and asked whether calcium supplementation increased their risk of developing cardiovascular disease.

- This study started with people who already had a form of cardiovascular disease associated with abnormal calcium metabolism and asked whether calcium supplementation increased their risk of dying from the disease.

The age of the people studied was very different.

- The earlier studies started with middle-aged adults and followed them for 10-20 years

- This study started with people in their mid-70’s and followed them for almost 6 years.

The type of cardiovascular disease studied was different.

- The earlier studies included all types of cardiovascular disease.

- This study focused on a very minor type of cardiovascular disease, aortic stenosis. Aortic stenosis accounts for about 10% of all cardiovascular disease 17% of cardiovascular deaths. There may not have been enough deaths from aortic stenosis in the previous studies to have had a statistically significant effect on the results.

Given all these differences, the results of this study may not be incompatible with the results of previous studies

What Does This Study Mean For You?

There are three important takeaways from this and previous studies:

1) For most Americans calcium supplementation does not increase the risk of cardiovascular disease. That has been shown in three major clinical studies.

2) However, if you have been diagnosed with aortic stenosis, calcium supplementation may increase your risk of needing heart valve replacement or of dying from the disease. This study is not definitive, but I would advise caution.

You may wish to discuss with your doctor how to best balance:

- The need for calcium supplementation to prevent osteoporosis…

- With the need to limit calcium supplementation to prevent adverse outcomes from your aortic stenosis.

3) Finally, the authors did not discuss a very significant observation from this study, namely that heart valve replacement reduced the risk of dying from aortic stenosis in people taking calcium supplements.

Aortic valve replacement is the only proven treatment for aortic stenosis. If your doctor recommends aortic valve replacement, you should consider it.

The Bottom Line

A recent study looked at the effect of calcium supplementation for people with aortic stenosis, a rare form of heart disease.

The study found:

Calcium supplementation increased the need for aortic valve replacement surgery by 50%.

Calcium supplementation increased the risk of all-cause mortality* by 31%. When you divided the results into patients who did and did not have aortic valve replacement surgery during the study:

- Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.

Calcium supplementation doubled the risk of cardiovascular mortality*. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:

- Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.

*Note: Since all the patients enrolled in this study had aortic stenosis at the beginning of the study, these deaths were primarily due to aortic stenosis.

There are three important takeaways from this and previous studies:

1) For most Americans calcium supplementation does not increase the risk of cardiovascular disease. That has been shown in three major clinical studies.

You may wish to discuss with your doctor how to best balance:

- The need for calcium supplementation to prevent osteoporosis…

- With the need to limit calcium supplementation to prevent adverse outcomes from your aortic stenosis.

Aortic valve replacement is the only proven treatment for aortic stenosis. If your doctor recommends aortic valve replacement, you should consider it.

For more details, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

The Omega-3 Pendulum

April 12, 2022 by Dr. Steve Chaney

Who Benefits Most From Omega-3s?

Author: Dr. Stephen Chaney

If you were around in the 60’s, you might remember the song “England Swings Like a Pendulum Do”. It was a cute song, but it had nothing to do with pendulums. This week I am talking about something that really does resemble a pendulum – the question of whether omega-3s reduce heart disease risk.

There is perhaps nothing more confusing to the average person than the “truth” about omega-3s and heart disease risk. The headlines and expert opinion on the topic swing wildly between “omega-3s reduce heart disease risk” to “omega-3s have no effect on heart disease risk” and back again. To me these swings resemble the swings of a pendulum – hence the title of this article.

Part of the reason for the wild swings is that journalists and most “experts” tend to rely on the latest study and ignore previous studies. Another contributing factor is that most journalists and experts read only the main conclusions in the article abstract. They don’t read and analyze the whole study.

So, in today’s “Health Tips From the Professor” I plan to:

Analyze 3 major studies that have influenced our understanding of the relationship between omega-3 intake and heart disease risk. I will tell you what the experts missed about these studies and why they missed it.

Summarize what you should know about omega-3 intake and your risk of heart disease.

Why Is The Role Of Omega-3s In Preventing Heart Disease So Confusing?

In answering that question, let me start with what I call “Secrets Only Scientists Know”.

#1: Each study is designed to disprove previous studies. That is a strength of the scientific method. But it guarantees there will be studies on both sides of every issue.

Responsible scientists look at all high-quality studies and base their opinions on the weight of evidence. Journalists and less-responsible “experts” tend to “cherry pick” the studies that match their opinions.

#2: Every study has its flaws. Even high-quality studies have unintended flaws. And I have some expertise in identifying unintended flaws.

I published over 100 papers that went through the peer review process. And I was involved in the peer review of manuscripts submitted by other scientists. In the discussion below I will use my experience in reviewing scientific studies to identify unintended flaws in 3 major studies on omega-3s and heart disease risk.

Next, let me share the questions I ask when reviewing studies on omega-3s and heart disease. I am just sharing the questions here. Later I will share examples of how these questions allowed me to identify unintended flaws in the studies I review below.

#1: How did they define heart disease? The headlines you read usually refer to the effect of omega-3s on “heart disease”. However, heart disease is a generic term. In layman’s terms, it encompasses angina, heart attacks, stroke due to blood clots, stroke due brain bleeds, congestive heart failure, impaired circulation, and much more.

Omega-3s have vastly different effects on different forms of heart disease, so it is important to know which form(s) of heart disease the study examined. And if the study included all forms of heart disease, it is important to know whether they also looked at the forms of heart disease where omega-3s have been shown to have the largest impact.

#2: What was the risk level of the patients in the study? If the patients in the study are at imminent risk of a heart attack or major cardiovascular event, it is much easier to show an effect than if they are at low risk.

For example, it is easy to show that statins reduce the risk of a second heart attack in someone who has just suffered a heart attack. These are high-risk patients. However, if you look at patients with high cholesterol but no other risk factors for heart disease, it is almost impossible to show a benefit of statins. These are low-risk patients.

If it is difficult to show that statins benefit low-risk patients, why should we expect to be able to show that omega-3s benefit low-risk patients?

[Note: I am not saying that statins do not benefit low-risk patients. I am just saying it is very difficult to prove they do in clinical studies.]

#3: How much omega-3s are the patients getting in their diet? The public reads the headlines. When the headlines say that omega-3s are good for their hearts, they tend to take omega-3 supplements. When the headlines say omega-3s are worthless, they cut back on omega-3 supplements. So, there is also a pendulum effect for omega-3 intake.

Omega-3s are fats. So, omega-3s accumulate in our cell membranes. The technical term for the amount of omega-3s in our cellular membranes is something called “Omega-3 Index”. Previous studies have shown that:

- An omega-3 index of 4% or less is associated with high risk of heart disease, and…

- An omega-3 index of 8% or more is associated with a low risk of heart disease.

When the omega-3 index approaches 8%, adding more omega-3 is unlikely to provide much additional benefit. Yet many studies either don’t measure or ignore the omega-3 index of patients they are enrolling in the study.

#4: How many and what drugs were the patients taking? Many heart disease patients are taking drugs that lower blood pressure, lower triglycerides, reduce inflammation, and reduce the risk of blood clot formation. These drugs do the same things that omega-3s do. This decreases the likelihood that you can see any benefit from increasing omega-3s intake.

The Omega-3 Pendulum

With all this in mind let’s examine three major double-blind, placebo-controlled studies that looked at the effect of omega-3s on heart disease risk and came to different conclusions. Here is a summary of the studies.

GISSI Study	ASCEND Study	VITAL Study
11,000 participants	15,480 participants	25,871 participants
Followed for 3.5 years	Followed for 7.4 years	Followed for 5.3 years
Europe	USA	USA
Published in 1999	Published in 2018	Published in 2019
Dose = 1 gm/day	Dose = 1 gm/day	Dose = 1 gm/day
20% ↓ in heart disease deaths	No effect on fatal or non-fatal heart attack or stroke	Significant ↓ in some forms of heart disease
45% ↓ in fatal heart attack or stroke – as effective as statins		Significant ↓ in heart disease risk for some patients

At first glance the study designs look similar, so why did these studies give such different results. This is where the unintended flaws come into play. Let’s look at each study in more detail.

The GISSI Study:

The patients enrolled in this study all had suffered a heart attack in the previous 3 months. They were at very high risk of suffering a second heart attack within the next couple of years.

Omega-3 intake was not measured in this study. But it was uncommon for Europeans to supplement with omega-3s in the 90’s. And European studies on omega-3 intake during that period generally found that omega-3 intake was low.

Patients enrolled in this study were generally taking only 2 heart disease drugs, a beta-blocker and a blood pressure drug.

The ASCEND Study:

The patients enrolled in this study had diabetes without any evidence of heart disease. Only 17% of the patients enrolled in the study were at high risk of heart disease. 83% were at low risk. Remember, it is difficult to show a benefit of any intervention in low-risk patients.

The average omega-3 index of patients enrolled in this study was 7.1%. That means omega-3 levels were near optimal at the beginning of the study. Adding additional omega-3s was unlikely to show much benefit.

Most of the patients in this study were on 3-5 heart drugs and 1-2 diabetes drugs which duplicated the effects of omega-3s.

That means this study was asking a very different question. It was asking whether omega-3s provided any additional benefit for patients who were already taking multiple drugs that duplicated the effects of omega-3s.

However, you would have never known that from the headlines. The headlines simply said this study showed omega-3s were ineffective at preventing heart disease.

Simply put, this study was doomed to fail. However, despite its many flaws the authors reported that omega-3s did reduce one form of heart disease, namely vascular deaths (primarily due to heart attack and stroke). Somehow this observation never made it into the headlines.

The VITAL Study:

This study enrolled a cross-section of the American population aged 55 or older (average age = 67). As you might suspect for a cross-section of the American population, most of the participants in this study were at low risk for heart disease. This limited the ability of the study to show a benefit of omega-3 supplementation in the whole population.

However, there were subsets of the group who were at high risk of heart disease (more about that below).

This study excluded omega-3 supplement users The average omega-3 index of patients enrolled in this study was 2.7% at the beginning of the study and increased substantially during the study. This enhanced the ability of the study to show a benefit of omega-3 supplementation.

Participants in this study were only using statins and blood pressure medications. People using more medications were excluded from the study. This also enhanced the ability of the study to show a benefit of omega-3 supplementation.

The authors reported that “Supplementation with omega-3 fatty acids did not result in a lower incidence of major cardiovascular events…” This is what lazy journalists and many experts reported about the study.

However, the authors designed the study so they could also:

Look at the effect of omega-3s on heart disease risk in high-risk groups. They found that major cardiovascular events were reduced by:

- 26% in African Americans.

- 26% in patients with diabetes.

- 17% in patients with a family history of heart disease.

- 19% in patients with two or more risk factors of heart disease.

Look at the effect of omega-3s on heart disease risk in people with low omega-3 intake. They found that omega-3 supplementation reduced major cardiovascular events by:

- 19% in patients with low fish intake.

Look at the effect of omega-3s on the risk of different forms of heart disease. They found that omega-3 supplementation reduced:

- Heart attacks by 28% in the general population and by 70% for African Americans.

- Deaths from heart attacks by 50%.

- Deaths from coronary heart disease (primarily heart attacks and ischemic strokes (strokes caused by blood clots)) by 24%.

In summary, if you take every study at face value it seems like the pendulum is constantly swinging from “omega-3s reduce heart disease risk” to “omega-3s are worthless” and back again. There appears to be no explanation for the difference in results from one study to the next.

However, if you remember that even good studies have unintended flaws and ask the four questions I proposed above, it all makes sense.

How is heart disease defined? Studies looking at heart attack and/or ischemic stroke are much more likely to show a benefit of omega-3s than studies that include all forms of heart disease.

Are the patients at low-risk or high-risk for heart disease? Studies in high-risk populations are much more likely to show a benefit than studies in low-risk populations.

What is the omega-3 intake of participants in the study? Studies in populations with low omega-3 intake are more likely to show a benefit of omega-3 supplementation than studies in populations with high omega-3 intake.

How many heart drugs are the patients taking? Studies in people taking no more than one or two heart drugs are more likely to show a benefit of omega-3 supplementation than studies in people taking 3-5 heart drugs.

When you view omega-3 clinical studies through the lens of these 4 questions, the noise disappears. It is easy to see why these studies came to different conclusions.

Who Benefits Most From Omega-3s?

The answers to this question are clear:

People at high risk of heart disease are most likely to benefit from omega-3 supplementation.

People with low omega-3 intake are most likely to benefit from omega-3 supplementation.

Omega-3 supplementation appears to have the biggest effect on heart attack and ischemic stroke (stroke due to blood clots). Its effect on other forms of heart disease is less clear.

Omega-3 supplementation appears to be most effective at preventing heart disease if you are taking no more than 1 or 2 heart drugs. It may provide little additional benefit if you are taking multiple heart drugs. However, you might want to have a conversation with your doctor about whether omega-3 supplementation might allow you to reduce or eliminate some of those drugs.

What about the general population? Is omega-3 supplementation useful for patients who are at low to moderate risk of heart disease?

If we compare omega-3 studies with statin studies, the answer would be yes. Remember that statins cannot be shown to reduce heart attacks in low-risk populations. However, because they are clearly effective in high-risk patients, the medical community assumes they should be beneficial in low-risk populations. The same argument could be made for omega-3s.

We also need to recognize that our ability to recognize those who are at high risk of heart disease is imperfect. For too many Americans, the first indication that they have heart disease is sudden death!

When I was still teaching, I invited a cardiologist to speak to my class of first year medical students. He told the students, only partly in jest, that he felt statins were so beneficial they “should be added to the drinking water”.

I feel the same way about omega-3s:

Most Americans do not get enough omega-3s in our diet.

Our omega-3 index is usually much closer to 4% (high risk of heart disease) than 8% (low risk of heart disease).

Many of us may not realize that we are at high risk of heart disease until it is too late.

And omega-3s have other health benefits.

For all these reasons, omega-3 supplementation only makes sense.

The Bottom Line

If you take every study at face value, there appears to be no explanation for the difference in results from one study to the next. However, if you recognize that even good studies have unintended flaws and ask four simple questions to expose these flaws, it all makes sense.

For the four questions you should ask when reviewing any omega-3 study and my recommendations for who benefits the most from omega-3 supplementation, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Eating Of The Green

March 29, 2022 by Dr. Steve Chaney

Why Is Eating Green Good For Your Heart?

Author: Dr. Stephen Chaney

You may be one of the millions of Americans who celebrated St. Patrick’s Day a couple of weeks ago. If so, you may have sung the famous Irish folk song “The Wearing of the Green”. If you are Irish, that song has special meaning for you. However, when I hear that song, I think of “Eating of the Green.”

And when I think of eating green, I don’t mean that everything we eat should be green. I am thinking of whole fruits and vegetables in a variety of colors. We have known for years that fruits and vegetables are good for our health. Consumption of fruits and vegetables is associated a lower risk of high blood pressure, heart disease, cancer, inflammatory diseases, and much more.

For today’s health tip, I am going to focus on heart health and an unexpected explanation for how fruits and vegetables reduce our risk of heart disease.

Why Is Eating Green Good For Your Heart?

We have assumed that whole fruits and vegetables lower our risk of heart disease because they are low in saturated fats and provide heart-healthy nutrients, phytonutrients, and fiber. All of that is true. But could there be more?

Recent research has suggested that the nitrates found naturally in fruits and vegetables may also play a role in protecting our hearts. Here is what recent research shows:

The nitrates from fruits and vegetables are converted to nitrite by bacteria in our mouth and intestines.

- Fruits and vegetables account for 80% of the nitrate in our diet. The rest comes from a variety of sources including the nitrate added as a preservative to processed meats.

- Although all fruits and vegetables contain nitrates, the best sources are green leafy vegetables and beetroot. [Beet greens are delicious and also a good source of nitrate, but beetroot is the part of the beet we usually consume.]

Nitrite is absorbed from our intestine and converted to nitric oxide by a variety of enzymes in our tissues.

Both reactions require antioxidants like vitamin C, which are also found in fruits and vegetables.

Nitric oxide has several heart healthy benefits. For example:

It helps reduce inflammation in the lining of blood vessels. Inflammation stimulates atherosclerosis, blood clot formation, and is associated with an increased risk of heart disease.

It relaxes the smooth muscle cells that surround our blood vessels. This makes the blood vessels more flexible and helps reduce blood pressure.

It prevents smooth muscle cells from proliferating, which prevents them from invading and constricting our arteries. This, in turn, has the potential to reduce the risk of atherosclerosis.

It prevents platelet aggregation. This, in turn, has the potential to reduce the risk of heart attack and stroke due to blood clots that block the flow of blood to our heart or brain.

It is well established that nitrates from fruits and vegetables reduce blood pressure. More importantly, they can help slow the gradual increase in blood pressure as we age.

However, few studies have asked whether this reduction in blood pressure translates into improved cardiovascular outcomes. This study (CP Bondonno et al, European Journal of Epidemiology, 36: 813-825, 2021) was designed to answer that question.

How Was This Study Done?

This study made use of data from the Danish Diet, Cancer, and Health Program. That program enrolled 53,150 participants from Copenhagen and Aarhus between 1993 and 1997 and followed them for an average of 21 years. None of the participants had a diagnosis of cancer or heart disease at the beginning of the study.

Other characteristics of the participants at the time they were enrolled in the study were:

46% male

Average age = 56

BMI = 26 (>20% overweight)

Average systolic blood pressure = 140 mg Hg

Average diastolic blood pressure = 84 mg Hg

At the beginning of the study, participants filled out a 192-item food frequency questionnaire that assessed their average intake of various food and beverage items over the previous 12 months. The vegetable nitrate content of their diets was analyzed using a comprehensive database of the nitrate content of 178 vegetables. For those vegetables not consumed raw, the nitrate content was reduced by 50% to account for the nitrate loss during cooking.

Blood pressure was measured at the beginning of the study. Data on the incidence (first diagnosis) of heart disease during the study was obtained from the Danish National Patient Registry. Data were collected on diagnosis of the following heart health parameters:

Cardiovascular disease (all diseases of the circulatory system).

Ischemic heart disease (lack of sufficient blood flow to the heart). The symptoms of ischemic heart disease range from angina to myocardial infarction (heart attack).

Ischemic stroke (lack of sufficient blood flow to the brain).

Hemorrhagic stroke (bleeding in brain).

Heart failure.

Peripheral artery disease (lack of sufficient blood flow to the extremities).

Is Nitrate From Vegetables Good For Your Heart?

Intake of nitrate from vegetables ranged from 18 mg/day (<1/3 serving of nitrate-rich vegetables per day) to 168 mg (almost 3 servings of nitrate-rich vegetables per day). The participants were grouped into quintiles based on their vegetable nitrate intake. When the group with the highest vegetable nitrate intake was compared to the group with the lowest vegetable nitrate intake:

Systolic blood pressure was reduced by 2.58 mg Hg.

Diastolic blood pressure was reduced by 1.38 mg Hg.

Risk of cardiovascular disease was reduced by 14%.

Risk of ischemic heart disease (angina and heart attack) was reduced by 13%.

Risk of ischemic stroke (stroke caused by lack of blood flow to the brain) was reduced by 14%.

Risk of heart failure was reduced by 17%.

Risk of peripheral artery disease was reduced by 31%.

Risk of hemorrhagic stroke (bleeding in the brain) was not significantly reduced.

Two other observations were of interest:

Blood pressure and risk of peripheral artery disease decreased with increasing vegetable nitrate intake in a relatively linear fashion. However, the other parameters of heart disease plateaued at a modest intake of vegetable nitrate intake (around one cup of nitrate-rich vegetables per day). This suggests that as little as one serving of nitrate-rich vegetables a day is enough to provide some heart health benefits.

Only about 21.9% of the improvement in heart health could be explained by the decrease in blood pressure. This is not surprising when you consider the other beneficial effects of nitric oxide described above.

The authors concluded, “Consumption of at least ~60 mg/day of vegetable nitrate (~ one serving of green leafy vegetables or beets) may mitigate risk of cardiovascular disease.”

Are Nitrates Good For You Or Bad For You?

You are probably thinking, “Wait a minute. I thought nitrates and nitrites were supposed to be bad for me. Which is it? Are nitrates good for me or bad for me?”

It turns out that nitrates and nitrites are kind of like Dr. Jekyll and Mr. Hyde. They can be either good or bad. It depends on the food they are in and your overall diet.

Remember the beginning of this article when I said that the conversion of nitrates to nitric oxide depended on the presence of antioxidants? Vegetables are great sources of antioxidants. So, when we get our nitrate from vegetables, most of it is converted to nitric oxide. And, as I discussed above, nitric oxide is good for us.

However, when nitrates and nitrites are added to processed meats as a preservative, the story is much different. Processed meats have zero antioxidants. And the protein in the meats is broken down to amino acids in our intestine. The amino acids combine with nitrate to form nitrosamines, which are cancer-causing chemicals. Nitrosamines are bad for us.

Of course, we don’t eat individual foods by themselves. We eat them in the context of a meal. If you eat small amounts of nitrate-preserved processed meats in the context of a meal with antioxidant-rich fruits and vegetables, some of the nitrate will be converted to nitric oxide rather than nitrosamines. The processed meat won’t be as bad for you.

Eating Of The Green

Your mother was right. You should eat your fruits and vegetables!

The USDA recommends at least 3 servings of vegetables and 2 servings of fruit a day.

Based on this study, at least one of those servings should be nitrate-rich vegetables like green leafy vegetables and beets.

If you don’t like any of those, radishes, turnips, watercress, Bok choy, Chinese cabbage, kohlrabi, chicory leaf, onion, and fresh garlic are also excellent sources of nitrate.

The good news is that you may not need to eat green leafy vegetables and beets with every meal. If this study is correct, one serving per day may have heart health benefits. That means you can enjoy a wide variety of fresh fruits and vegetables as you try to meet the USDA recommendations.

Finally, if you don’t like any of those foods, you may be asking, “Can’t I just take a nitrate supplement?”

For blood pressure, there are dozens of clinical trials, and the answer seems to be yes – especially when the nitrate comes from vegetable sources and the supplement also contains an antioxidant like vitamin C.

For heart health benefits, the answer is likely to be yes, but clinical trials to confirm that would take decades. Double blind, placebo-controlled trials of that duration are not feasible, so we will never know for sure.

Moreover, you would not be getting all the other health benefits of a diet full of fresh fruits and vegetables. Supplementation has its benefits, but it is not meant to replace a healthy diet.

The Bottom Line

We have known for years that fruits and vegetables are good for our hearts. We have assumed that was because whole fruits and vegetables are low in saturated fats and provide heart-healthy nutrients, phytonutrients, and fiber. But could there be more?

It is well established that nitrates from fruits and vegetables reduce blood pressure. More importantly, they can help slow the gradual increase in blood pressure as we age.

However, few studies have asked whether this reduction in blood pressure translates into improved cardiovascular outcomes. A recent study was designed to answer that question.

When the study compared people with the highest vegetable nitrate intake to people with the lowest vegetable nitrate intake:

Blood pressure was significantly reduced.

The risk of cardiovascular disease was reduced by 14%.

Risk of ischemic heart disease (angina and heart attack) was reduced by 13%.

Risk of ischemic stroke (stroke caused by lack of blood flow to the brain) was reduced by 14%.

Risk of heart failure was reduced by 17%.

Risk of peripheral artery disease was reduced by 31%.

Blood pressure and risk of peripheral artery disease decreased with increasing vegetable nitrate intake in a relatively linear fashion.

However, the other parameters of heart disease plateaued at a modest intake of vegetable nitrate intake (around one cup of nitrate-rich vegetables per day). This suggests that as little as one serving of nitrate-rich vegetables a day is enough to provide some heart health benefits.

The authors concluded, “Consumption of at least ~60 mg/day of vegetable nitrate (~ one serving of green leafy vegetables or beets) may mitigate risk of cardiovascular disease.”

Of course, you may have heard that nitrates and nitrites are bad for you. I discuss that in the article above.

For more details about this study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Does Olive Oil Help You Live Longer?

March 8, 2022 by Dr. Steve Chaney

Which Fat Is Healthiest?

Author: Dr. Stephen Chaney

If you believe the headlines, olive oil is a superfood. It is often described as the star of the Mediterranean diet. It is referred to as the healthiest of dietary fats. Is this true, or is it hype?

Olive oil’s resume is impressive:

It is rich in monounsaturated fatty acids, which…

- Are less susceptible to oxidation than polyunsaturated oils.

- Make our arteries more flexible, which lowers blood pressure.

- Lower LDL-cholesterol levels, which reduces the risk of heart disease.

Extra-virgin olive oil contains phytonutrients and tocopherols (various forms of vitamin E), which…

- Have anti-inflammatory properties.

- Improve insulin sensitivity and blood sugar control.

Olive oil consumption is also associated with healthier gut bacteria, but it is not clear whether this is due to olive oil or to the fact that a Mediterranean diet is also richer in fresh fruits, vegetables, and whole grains.

Several recent studies have shown that olive oil consumption is associated with a lower risk of heart disease. However, these studies were conducted in Mediterranean countries where the average intake of olive oil (3 tablespoons/day) is much greater than in the United States (0.3 tablespoons/day).

The current study (M Guasch-Ferré et al, Journal of the American College of Cardiology, 79: 101-112, 2022) was designed to test whether:

The amount of olive oil Americans consume decreases the risk of heart disease.

Whether olive oil consumption had benefits beyond a reduction in heart disease risk.

How Was This Study Done?

This study combined data from 60,582 women enrolled in the Nurses’ Health Study and 31,801 men enrolled in the Health Professionals Follow-Up Study). The participants:

Were free of heart disease and diabetes at the start of the study.

Were 56 at the start of the study with an average BMI of 25.6 (Individuals with BMIs in the 25-30 range are considered overweight, so they were at the lowest end of the overweight range).

The Nurses’ Health Study and Health Professional Follow-Up Study are both association studies, meaning they looked at the association between olive oil consumption and health outcomes. They cannot directly prove cause and effect. However, they are very strong association studies because:

Every 2 years, participants filled out a questionnaire that updated information on their body weight, smoking status, physical activity, medications, multivitamin use, and physician-diagnosed diseases.

Every 4 years, participants filled out a comprehensive food frequency questionnaire.

In other words, this study did not just rely on the participant’s lifestyle, dietary intake, and health at the beginning of the study, as so many association studies do. It tracked how each of these variables changed over time.

The participants were followed for an average of 28 years and their average olive oil intake over those 28 years was correlated with all-cause mortality and mortality due to specific diseases.

Deaths were identified from state vital statistics, the National Death index, reports by next of kin, or reports by postal authorities.

Causes of death were determined by physician review of medical records, medical reports, autopsy reports, or death certificates.

Does Olive Oil Help You Live Longer?

During the 28 years of this study:

Olive oil consumption in the United States increased from an average of ~1/3 teaspoon/day to ~1/3 tablespoon/day.

Margarine consumption decreased from 12 g/day to ~4 g/day.

The consumption of all other fats and oils remained about the same.

As I mentioned above, olive oil consumption was averaged over the life of the study for each individual. When the investigators compared people consuming the highest amount of olive oil (>0.5 tablespoon/day) with people consuming the least olive oil (0 to 1 teaspoon/day):

Mortality from all causes was decreased by 35% for the group consuming the most olive oil.

However, the group consuming the most olive oil also was more physically active, had a healthier diet, and consumed more fruits and vegetables than the group who consumed the least olive oil.

After correcting for all those factors, mortality from all causes was decreased by 19% for the group consuming the most olive oil.

The authors concluded, “We found that greater consumption of olive oil was associated with lower risk of total…mortality… Our results support current dietary recommendations to increase the intake of olive oil…to improve overall health and longevity.” (I will fill in the blanks in this statement once I have covered other aspects of this study)

The authors also said, “Of note, our study showed that benefits of olive oil can be observed even when consumed in lower amounts than in Mediterranean countries.”

Are There Other Benefits From Olive Oil Consumption?

The study didn’t stop there. The investigators also looked at the effect of olive oil consumption on the major killer diseases in the United States and other developed countries. When they compared the effect of olive oil consumption on cause-specific mortality, they found that the group who consumed the most olive oil reduced their risk of dying from:

Cardiovascular disease by 19%.

Cancer by 17%

Respiratory disease by 18%.

Neurodegenerative disease (cognitive decline and Alzheimer’s disease) by 29%.

- The reduction in neurodegenerative disease was much greater for women (34% decrease) than for men (19% decrease).

With this information I can fill in one of the blanks in the author’s conclusions: “We found that greater consumption of olive oil was associated with lower risk of total and cause-specific mortality… Our results support current dietary recommendations to increase the intake of olive oil…to improve overall health and longevity.”

Which Fats Are Healthiest?

The sample size was large enough and the dietary information complete enough for the investigators to also estimate the effect of substituting olive oil for other dietary fats and oils.

They found that every ¾ tablespoon of olive oil substituted for an equivalent amount of:

Margarine decreased total mortality by 13%.

Butter decreased total mortality by 14%.

Mayonnaise deceased total mortality by 19%

Dairy fat decreased total mortality by 13%.

- The same beneficial effects of substituting olive oil for other fats were seen for cause-specific mortality (cardiovascular disease, cancer, respiratory disease, and neurodegenerative disease).

- There was a linear dose-response. This means that substituting twice as much olive oil for other dietary fats doubled the beneficial effects on total and cause-specific mortality.

However, substituting olive oil for polyunsaturated vegetable oils had no effect on total and cause-specific mortality.

Now I can fill in the remaining blanks in the author’s conclusion: “We found that greater consumption of olive oil was associated with lower risk of total and cause-specific mortality. Replacing other types of fat, such as margarine, butter, mayonnaise, and dairy fat, with olive oil was also associated with a lower risk of mortality. Our results support current dietary recommendations to increase the intake of olive oil and other unsaturated vegetable oils in place of other fats to improve overall health and longevity.”

What Does This Study Mean For Us?

As I said above, this is an association study, and association studies do not prove cause and effect. However:

1) This is a very strong association study because:

- It is a very large study (92,383 participants).

- It followed the participants over a long time (28 years).

- It utilized a very precise dietary analysis.

- Most importantly, it tracked the participant’s lifestyle, dietary intake, and health at regular intervals throughout the study. Most association studies only measure these variables at the beginning of the study. They have no idea how they change over time.

2) This study is consistent with several previous studies showing that olive oil consumption decreases the risk of dying from heart disease.

3) This study draws on its large population size and precise dietary analysis to strengthen and extend the previous studies. For example:

- The study showed that increased olive oil consumption also reduced total mortality and mortality due to cancer, respiratory disease, and neurodegenerative disease.

- The study measured the effect of substituting olive oil for other common dietary fats.

- The study showed that increased olive oil consumption in the context of the American diet was beneficial.

I should point out that the headlines you have seen about this study may be misleading.

While the headlines may have depicted olive oil as a superfood, this study did not find evidence that olive oil was more beneficial than other unsaturated vegetable oils. Again, this is consistent with many previous studies showing that substituting vegetable oils for other dietary fats reduces the risk of multiple diseases.

The headlines focused on the benefits of increasing olive oil consumption. However, they neglected the data showing that increasing olive oil (and other vegetable oils) was even more beneficial (35% reduction in total mortality) in the context of a healthy diet – one with increased intake of fruits, vegetables, whole grains, nuts, legumes, and long-chain omega-3s and decreased intake of red & processed meats, sodium, and trans fats.

So, my recommendation is to follow a whole food, primarily plant-based diet and substitute extra-virgin olive oil and cold pressed vegetable oils for some of the animal fats in your diet.

Some vegan enthusiasts recommend a very low-fat whole food plant-based diet. They point to studies showing that such diets can actually reverse atherosclerosis. However:

Those studies are very small.

The overall diet used in those studies is a very healthy plant-based diet.

The studies did not include a control group following the same diet with olive oil or other vegetable oils added to it, so there is no comparison of a healthy vegan diet with and without vegetable oils.

If you have read my book, “Slaying the Food Myths”, you know that my recommendations encompass a variety of whole food, primarily plant-based diets ranging all the way from very-low fat vegan diets to Mediterranean and DASH diets. Choose the one that best fits your food preferences and the one you will be most able to stick with long term. You will be healthier, and you may live longer.

The Bottom Line

A recent study looked at the effect of olive oil consumption on the risk dying from all causes and from heart disease, cancer, respiratory disease, and neurodegenerative diseases. When the study compared people consuming the highest amount of olive oil (>0.5 tablespoon/day) with people consuming the least olive oil (0 to 1 teaspoon/day):

Mortality from all causes was decreased by 19% for the group consuming the most olive oil.

They also found that the group who consumed the most olive oil reduced their risk of dying from:

Cardiovascular disease by 19%.

Cancer by 17%

Respiratory disease by 18%.

Neurodegenerative disease (cognitive decline and Alzheimer’s disease) by 29%.

They also found that every ¾ tablespoon of olive oil substituted for an equivalent amount of:

Margarine decreased total mortality by 13%.

Butter decreased total mortality by 14%.

Mayonnaise deceased total mortality by 19%

Dairy fat decreased total mortality by 13%.

However, substituting olive oil for polyunsaturated vegetable oils had no effect on total and cause-specific mortality.

The authors concluded, “We found that greater consumption of olive oil was associated with lower risk of total and cause-specific mortality. Replacing other types of fat, such as margarine, butter, mayonnaise, and dairy fat, with olive oil was also associated with a lower risk of mortality. Our results support current dietary recommendations to increase the intake of olive oil and other unsaturated vegetable oils in place of other fats to improve overall health and longevity.”

For more details and a summary of what this study means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Who Benefits Most From Supplementation?

February 8, 2022 by Dr. Steve Chaney

Supplements Are Part of a Holistic Lifestyle

Author: Dr. Stephen Chaney

The headlines about supplementation are so confusing. Are they useful, or are they a waste of money? Will they cure you, or will they kill you? I feel your pain.

I have covered these questions in depth in my book, “Slaying The Supplement Myths”, but let me give you a quick overview today. I call it: “Who Benefits Most From Supplementation?” I created the graphic on the left to illustrate why I feel responsible supplementation is an important part of a holistic lifestyle for most Americans. Let me give you specific examples for each of these categories.

Examples of Poor Diet

You have heard the saying that supplementation fills in the nutritional gaps in our diets, so what are the nutritional gaps? According to the USDA’s 2020-2025 Dietary Guidelines for Americans, many Americans are consuming too much fast and convenience foods. Consequently, we are getting inadequate amounts of calcium, magnesium, and vitamins A, D, E and C. Iron is considered a nutrient of concern for young children and pregnant women. In addition, folic acid, vitamin B6, and iodine are nutrients of concern for adolescent girls and pregnant women.

According to a recent study, regular use of a multivitamin is sufficient to eliminate all these deficiencies except for calcium, magnesium and vitamin D (J.B. Blumberg et al, Nutrients, 9(8): doi: 10.3390/nu9080849, 2017). A well-designed calcium, magnesium and vitamin D supplement may be needed to eliminate those deficiencies.

In addition, intake of omega-3 fatty acids from foods appears to be inadequate in this country. Recent studies have found that American’s blood levels of omega-3s are among the lowest in the world and only half of the recommended level for reducing the risk of heart disease (K.D. Stark et al, Progress In Lipid Research, 63: 132-152, 2016; S.V. Thuppal et al, Nutrients, 9, 930, 2017; M Thompson et al, Nutrients, 11: 177, 2019). Therefore, omega-3 supplementation is often a good idea.

In previous editions of “Health Tips From the Professor” I have talked about our “mighty microbiome”, the bacteria and other microorganisms in our intestine. These intestinal bacteria can affect our tendency to gain weight, our immune system, inflammatory diseases, chronic diseases such as diabetes, cancer, and heart diseases, our mood—the list goes on and on. This is an emerging science. We are learning more every day, but for now it appears our best chances for creating a health-enhancing microbiome are to consume a primarily plant-based diet and take a probiotic supplement.

Finally, diets that eliminate whole food groups create nutritional deficiencies. For example, vegan diets increase the risk of deficiencies in vitamin B12, vitamin D, calcium, iron, zinc and long chain omega-3 fatty acids. A recent study reported that the Paleo diet increased the risk of calcium, magnesium, iodine, thiamin, riboflavin, folate and vitamin D deficiency (A. Genomi et al, Nutrients, 8, 314, 2016). The Keto diet is even more restrictive and is likely to create additional deficiencies.

Examples of Increased Need

We have known for years that pregnancy and lactation increase nutritional requirements. In addition, seniors have increased needs for protein, calcium, vitamin D and vitamin B12. In previous issues of “Health Tips From the Professor” I have also shared recent studies showing that protein requirements are increased with exercise.

Common medications also increase our need for specific nutrients. For example, seizure medications can increase your need for vitamin D and calcium. Drugs to treat diabetes and acid reflux can increase your need for vitamin B12. Other drugs increase your need for vitamin B6, folic acid, and vitamin K. Excess alcohol consumption increases your need for thiamin, folic acid, and vitamin B6. These are just a few examples.

Vitamin D is a special case. Many people with apparently adequate intake of vitamin D have low blood levels of 25-hydroxy vitamin D. It is a good idea to have your blood 25-hydroxy vitamin D levels measured on an annual basis and supplement with vitamin D if they are low.

More worrisome is the fact that we live in an increasing polluted world and some of these pollutants may increase our needs for certain nutrients. For example, in a recent edition of “Health Tips From the Professor” I shared a study reporting that exposure to pesticides during pregnancy increases the risk of giving birth to children who will develop autism, and that supplementation with folic acid during pregnancy reduces the effect of pesticides on autism risk. I do wish to acknowledge that this is a developing area of research. This and similar studies require confirmation. It is, however, a reminder that there may be factors beyond our control that have the potential to increase our nutritional needs.

Examples of Genetics Influencing Nutritional Needs

The effect of genetic variation on nutritional needs is known as nutrigenomics. One of the best-known examples of nutrigenomics is genetic variation in the methylenetetrahydrofolate reductase (MTHFR) gene. MTHFR gene mutations increase the risk of certain birth defects, such as neural tube defects. MTHFR mutations also slightly increase the requirement for folic acid. A combination of food fortification and supplementation with folic acid have substantially decreased the prevalence of neural tube defects in the US population. This is one of the great success stories of nutrigenomics. Parenthetically, there is no evidence that methylfolate is needed to decrease the risk of neural tube defects in women with MTHFR mutations.

Let me give you a couple of additional examples:

One of them has to do with vitamin E and heart disease (A.P. Levy et al, Diabetes Care, 27: 2767, 2004). Like a lot of other studies there was no significant effect of vitamin E on cardiovascular risk in the general population. But there is a genetic variation in the haptoglobin gene that influences cardiovascular risk. The haptoglobin 2-2 genotype increases oxidative damage to the arterial wall, which significantly increases the risk of cardiovascular disease. When the authors of this study looked at the effect of vitamin E in people with this genotype, they found that it significantly decreased heart attacks and cardiovascular deaths.

This has been confirmed by a second study specifically designed to look at vitamin E supplementation in that population group (F. Micheletta et al, Arteriosclerosis, Thrombosis and Vascular Biology, 24: 136, 2008). This is an example of a high-risk group benefiting from supplementation, but in this case the high risk is based on genetic variation.

Let’s look at soy and heart disease as a final example. There was a study called the ISOHEART study (W.L. Hall et al, American Journal of Clinical Nutrition, 82: 1260-1268, 2005 (http://ajcn.nutrition.org/content/82/6/1260.abstract); W.L. Hall et al, American Journal of Clinical Nutrition, 83: 592-600, 2006) that looked at a genetic variation in the estrogen receptor which increases inflammation and decreases levels of HDL. As you might expect, this genotype significantly increases cardiovascular risk.

Soy isoflavones significantly decrease inflammation and increase HDL levels in this population group. But they have no effect on inflammation or HDL levels in people with other genotypes affecting the estrogen reception. So, it turns out that soy has beneficial effects, but only in the population that’s at greatest risk of cardiovascular disease, and that increased risk is based on genetic variation.

These examples are just the “tip of the iceberg”. Nutrigenomics is an emerging science. New examples of genetic variations that affect the need for specific nutrients are being reported on a regular basis. We are not ready to start genotyping people yet. We don’t yet know enough to design a simple genetic test to predict our unique nutritional needs. That science is 10-20 years in the future, but this is something that’s coming down the road.

What the current studies tell us is that some people are high-risk because of their genetic makeup, and these are people for whom supplementation is going to make a significant difference. However, because genetic testing is not yet routine, most people are completely unaware that they might be at increased risk of disease or have increased nutritional requirements because of their genetic makeup.

Examples of Disease Influencing Nutritional Needs

Finally, let’s consider the effect of disease on our nutritional needs. If you look at the popular literature, much has been written about the effect of stress on our nutritional needs. In most case, the authors are referring to psychological stress. In fact, psychological stress has relatively minor effect on our nutritional needs.

Metabolic stress, on the other hand, has major effects on our nutritional needs. Metabolic stress occurs when our body is struggling to overcome disease, recover from surgery, or recover from trauma. When your body is under metabolic stress, it is important to make sure your nutritional status is optimal.

The effects of surgery and trauma on nutritional needs are well documented. In my book, “Slaying The Supplement Myths”, I discussed the effects of disease on nutritional needs in some detail. Let me give you a brief overview here. It is very difficult to show beneficial effects of supplementation in a healthy population (primary prevention). However, when you look at populations that already have a disease, or are at high risk for disease, (secondary prevention), the benefits of supplementation are often evident.

For example, studies suggest that vitamin E, B vitamins, and omega-3s each may reduce heart disease risk, but only in high-risk populations. Similarly, B vitamins (folic acid, B6 and B12) appear to reduce breast cancer risk in high risk populations.

Who Benefits Most From Supplementation?

With this information in mind, let’s return to the question: “Who benefits most from supplementation? Here is my perspective.

1) The need for supplementation is greatest when these circles overlap, as they do for most Americans.

2) The problem is that while most of us are aware that our diets are not what they should be, we are unaware of our increased needs and/or genetic predisposition. We are also often unaware that we are at high risk of disease. For too many Americans the first indication they have heart disease is sudden death, the first indication of high blood pressure is a stroke, or the first indication of cancer is a diagnosis of stage 3 or 4 cancer.

So, let’s step back and view the whole picture. The overlapping circles are drawn that way to make a point. A poor diet doesn’t necessarily mean you have to supplement. However, when a poor diet overlaps with increased need, genetic predisposition, disease, or metabolic stress, supplementation is likely to be beneficial. The more overlapping circles you have, the greater the likely benefit you will derive from supplementation.

That is why I feel supplementation should be included along with diet, exercise, and weight control as part of a holistic approach to better health.

The Bottom Line

In this article I provide a perspective on who benefits most from supplementation and why. There are four reasons to supplement.

Fill Nutritional gaps in our diet

2) Meet increased nutritional needs due to pregnancy, lactation, age, exercise, many common medications, and environmental pollutants.

3) Compensate for genetic variations that affect nutritional needs.

4) Overcome needs imposed by metabolic stress due to trauma, surgery, or disease.

With this information in mind, let’s return to the question: “Who benefits most from supplementation? Here is my perspective.

A poor diet alone doesn’t necessarily mean you have to supplement. However, when a poor diet overlaps with increased need, genetic predisposition, or metabolic stress, supplementation is likely to be beneficial. The more overlap you have, the greater the likely benefit you will derive from supplementation.

For more details, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Is Dairy Bad For Your Heart?

December 7, 2021 by Dr. Steve Chaney

Is Dairy Right For You?

Author: Dr. Stephen Chaney

We have been told for years that dairy foods are good for us. They are part of the USDA five food groups. In fact, they are part of the dietary recommendations of every government and most health organizations across the world.

And dairy foods are nutritious. They are excellent sources of calcium, potassium, protein, and vitamins A and B12. And if they are fortified, they are also an excellent source of vitamin D. Many health experts consider them essential for healthy bones. So, you might be saying, “Case closed. We should all be eating more dairy foods”.

But, not so fast. Many dairy foods are high in saturated fats. In fact, 65% of the fat in dairy foods is saturated. We have known for years that when saturated fats replace polyunsaturated fats in the diet, LDL cholesterol levels increase. And, as I reported in a previous issue of “Health Tips From the Professor” there is excellent evidence that replacing polyunsaturated fats with saturated fats substantially increases the risk of dying from heart attack, stroke, and other forms of heart disease.

The widely accepted message from these studies is that saturated fats raise LDL cholesterol levels and increases our risk of dying from heart disease. If we accept this message, it poses a dilemma. Dairy foods are nutritious. But they are high in saturated fat. What should we do?

The answer from the American Heart Association and most other health organizations is simple. We should eat low-fat dairy foods.

But this is where it gets really confusing. Dairy foods are composed of much more than saturated fats. And you have probably seen the claims that full fat dairy foods don’t increase the risk of heart disease.

So, what is the truth about full-fat dairy foods and heart health? In this issue of “Health Tips From The Professor” I review three recent studies and the recommendations of the Heart Foundation because they shed light on this question.

Is Dairy Bad For Your Heart?

Before I answer this question, I should point out that there are two ways of looking at it.

As I said above, the studies proving that saturated fats increase the risk of heart disease, substituted saturated fats for polyunsaturated fats and controlled every other aspect of the diet. That has led the American Heart Association and other organizations to recommend that we eat low-fat dairy foods.

However, when most people hear that recommendation, they simply substitute low-fat dairy for full-fat dairy foods without changing any other aspect of their diet or lifestyle. The first two studies were designed to see if that approach was effective for reducing heart disease risk.

The first study (KA Schmidt et al, American Journal of Clinical Nutrition, 114: 882-892, 2021) was a randomized controlled trial that compared the effect of low-fat dairy foods and full-fat dairy foods on heart health parameters.

The participants in this study were:

Average age = 62
56% male
75% white
Average weight = 214 pounds
All of them were prediabetic

All participants were told to stick with their usual diets (probably typical American diets) except for the amount and type of dairy foods added to their diet. During the first four weeks they restricted dairy consumption to 3 servings of nonfat dairy/week so they would all be starting with the same amount of dairy consumption. Then they were divided into 3 groups for the 12-week study:

Group 1 continued with 3 servings of nonfat dairy/week.
Group 2 added 3 servings of low-fat dairy/day to their usual diet.
Group 3 added 3 servings of high-fat dairy/day to their usual diet.

At the beginning of the study and again at the end of the 12-week study LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, and blood pressure were measured. The results were:

There was no difference in LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, or blood pressure in the three groups at the end of 12 weeks.

There was no also significant change in LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, or blood pressure during the study in any of the three groups.

The authors concluded, “A diet rich in full-fat dairy had no effect on fasting lipid profile or blood pressure compared with diets limited in dairy or rich in low-fat dairy. Therefore, dairy fat, when consumed as part of complex whole foods does not adversely affect these classic cardiovascular disease risk factors.”

[Note: The last sentence is key. Remember the “proof” that saturated fats increase LDL levels and increase the risk of heart disease come from studies in which saturated fats were substituted for polyunsaturated fats and every other aspect of the diet was carefully controlled.

In this study, and others like it, the effects of saturated fats are studied in a complex food (dairy) in the presence of an even more complex diet containing many foods that influence the risk of heart disease.]

The second study (J Guo et al, European Journal of Epidemiology 32: 269-287, 2017) was a meta-analysis of 29 studies with 938,465 participants looking at the association of full-fat dairy consumption with the risk of dying from heart disease.

Seven of the 29 studies were conducted in the United States. Of the remaining studies 3 were from Japan and Taiwan, 2 were from Australia, and 17 were from Europe.

The results of the study were:

There was no association between full-fat dairy, low-fat dairy, and total dairy consumption and risk of dying from heart disease.

When the results were broken down into individual dairy foods.

There was no association between milk consumption and risk of dying from heart disease.

Consumption of one serving/day of fermented dairy foods was associated with a 2% decreased risk of dying from heart disease.

The authors concluded, “The current meta-analysis of 29 prospective cohort studies suggested no association of total, high and low-fat dairy and milk with risk of cardiovascular disease. In addition, a possible role of fermented dairy was found in cardiovascular disease prevention, but the result was driven by a single study.” [I would add that this effect, if confirmed by subsequent studies, is extremely small (2%).]

The first two studies do not say that full-fat dairy foods are heart healthy for everyone, as some headlines would have you believe. Instead, these studies show fairly convincingly that simply switching from full-fat to low-fat dairy foods, without changing any other aspect of your diet and lifestyle, is not as effective at decreasing your risk of heart disease as some experts would have you believe.

The third publication (WC Willett and DS Ludwig, New England Journal of Medicine 382: 644-654, 2020) was a review of the effect of dairy foods on our health. One of the authors, Walter C Willett, is one of the top experts in the field. The review covered many topics, but I will focus on the section dealing with the effect of dairy foods on heart health.

This review took a more nuanced look at full-fat dairy foods and examined the effect of substituting full-fat dairy for other protein foods.

The review concludes, “The association of milk with the risk of cardiovascular disease depends on the comparison foods. In most cohort studies [such as the studies described above], no specific comparison was made; by default, the comparison was everything else in the diet – typically large amounts of refined grains, potato products, sugar, and meat.”

The review went on to say that previous studies have shown:

“Both full-fat and low-fat dairy foods…were associated with a lower risk [of cardiovascular disease and stroke] than…the same number of servings of red meat but with a higher risk than seen with the same number of servings of fish or nuts.”

“Dairy fat…was associated with a higher risk of cardiovascular disease than was polyunsaturated or vegetable fat.”

“For persons living in low-income countries where diets are very high in starch, moderate intake of dairy foods may reduce cardiovascular disease by providing nutritional value and reducing glycemic load [the amount of easily digestible carbohydrate in the diet].”

Is Dairy Right For You?

Now I am ready to answer the question posed at the beginning of this article, “Is dairy bad for your heart?” The answer is, “It depends”.

As described above, the effect of dairy on heart health depends on our overall diet. It also depends on our lifestyle, our weight, and our health.

In addition, clinical studies report averages, and none of us are average. We all have unique diets, lifestyles, health status, and genetic makeup.

So, what does this mean for you? Perhaps it is best summed up by the recommendations of Australia’s Heart Foundation which take health status, lifestyle, and genetic differences into account:

A heart healthy diet can include dairy, but it is not essential [with careful planning and/or supplementation you can get your calcium and protein elsewhere].

Milk, yogurt, and cheese are considered neutral for heart health, meaning they neither increase nor decrease the risk of heart disease for the average person. However, the recommendations vary depending on health status, genetics, and lifestyle:

- Low-fat milk, yogurt, and cheese are recommended for people with heart disease or high cholesterol because the fat in dairy foods can raise cholesterol more for these people. [Note: If cholesterol is elevated, it usually means that individual has a hard time regulating blood cholesterol levels because of obesity, genetics, or pre-existing disease. For these individuals, diets high in saturated fat are more likely to increase LDL cholesterol and risk of heart disease.]

- Full-fat milk, yogurt, and cheese can be part of a heart healthy diet for healthy people provided most of the fat in the diet comes from fish, nuts, seeds, and healthy oils. [Note: Overall diet is important.]

Choosing unflavored milk, yogurt, and cheese helps limit the amount of sugar in your diet.

Ice cream, cream, and dairy desserts should be eaten only sometimes and in small amounts because they have more sugar and fat, and less protein, vitamins, and minerals than other dairy foods.

Butter raises LDL cholesterol levels, especially in people who already have elevated cholesterol.

- There is no evidence that butter can be part of a heart healthy diet, so you should consider healthier options such as olive oil, avocado, nut butters, and spreads made with healthier oils, such as olive oil.

The Bottom Line

However, dairy foods have been controversial in recent years. Some experts claim that only low-fat dairy products can be heart healthy. Others claim that full-fat dairy foods are just as healthy as low-fat dairy foods.

I shared three recent publications and dietary recommendations from The Heart Foundation that shed light on these controversies.

The first study found that full-fat dairy foods did not increase LDL cholesterol, triglycerides, and other heart disease risk factors.

The second study was a meta-analysis of 29 clinical studies with almost one million people. It found that full-fat dairy foods did not increase the risk of dying from heart disease.

“Case closed”, you might say. However, these studies do not say that full-fat dairy foods are heart healthy for everyone, as some headlines would have you believe. Instead, these studies show fairly convincingly that simply switching from full-fat to low-fat dairy foods, without changing any other aspect of your diet and lifestyle, is not as effective at decreasing your risk of heart disease as some experts would have you believe.

Moreover, these studies do not account for the effect of overall diet, lifestyle, health status, and genetics on the risk of heart disease.

That is why I included the third study in my review. It took the overall diet into account and concluded the effect of full-fat dairy foods on heart disease risk depends on the overall diet.

For some diets full-fat dairy increases heart disease risk.

For other diets full-fat dairy has no effect on heart disease risk.

And for some diets full-fat dairy may even decrease heart disease risk.

Finally, I included recommendations of the Australian Heart Foundation because they included the effect of health status, lifestyle, and genetics in their recommendations.

For more details on the findings of the third study and the recommendations of the Heart Foundation, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Is It Too Late To Change Your Diet?

October 12, 2021 by Dr. Steve Chaney

You Can Improve Your Health At Any Age

Author: Dr. Stephen Chaney

If you are like most Americans, your dietary preferences as an adult are based on the foods your family ate while you were growing up.

Your favorite foods…

Your comfort foods…

The foods you always avoid…

…are based on your family heritage, not on your genes. And if you are like most Americans, your diet isn’t healthy.

It’s high in fat and cholesterol…

It’s high in sugar and refined carbohydrates…

It’s high in processed foods…

It’s low in whole, unprocessed foods…

It’s high in calories, so your waistline keeps growing.

You know your diet isn’t healthy, but you keep coasting along through your 30’s and 40’s until…the unthinkable happens. You are diagnosed with a deadly disease, like heart disease, high blood pressure, or diabetes, and your doctor says that unless you change your diet, you are doomed to a short unhealthy life. You have reached a fork in the road.

Changing the diet you grew up with, the diet you love, is a daunting task. It’s tempting to think, “Why bother…

It’s probably too late to change my diet…

The damage has already been done…

I can’t reverse it now.”

If this scenario describes you or someone you love, you aren’t alone. There are millions of Americans just like you. You want to know whether changing your diet is worth the trouble. You want to know whether it is too late, or whether you can still change your health for the better.

Most clinical studies don’t answer this question. Most clinical studies do a diet assessment at the beginning of the study and look at health outcomes 20 or 30 years later. If they do more than one diet assessment during the study, the purpose of these assessments is to show that most people stick to the same diet throughout the study.

These studies measure the effect of habitual diets on health outcomes. They tell you that good diets lead to good health outcomes, and bad diets lead to bad health outcomes. But they don’t tell you whether changing your diet from bad to good in your 30’s or 40’s can have a significant effect on your health.

Fortunately, a recent study has answered this question. This study (Y Choi et al, Journal of The American Heart Association, 10e020718, 2021) started with people in their mid-20s. It looked at whether changing their diet from bad to good in their 30s and 40s had any effect on their risk of developing heart disease in their 50s and 60s.

How Was This Study Done?

The data for this study were obtained from the CARDIA study (Coronary Artery Risk Development in Young Adults). The study enrolled 4946 young adults (average age = 25, 55% female and 45% male, 50% black and 50% white) and followed them for 32 years (average age of participants at the end of the study = 57).

Diet was assessed by a trained interviewer at year 0, year 7 (average age of participants = 32), and year 20 (average age of participants = 45).

Adherence of the participants to a healthy, plant-centered diet was assessed using an analytical tool called APDQS that divided the foods eaten by the participants into 3 groups based on their known influence on heart disease:

1) Beneficial.

- These foods included fruit, avocado, beans/legumes, green vegetables, yellow vegetables, tomatoes, other vegetables, nuts and seeds, soy products, whole grains, vegetable oil, fatty fish, lean fish, poultry, moderate alcohol, coffee, tea, and low-fat milk/cheese/yogurt.

- This is what the investigators considered a plant-centered diet. It encompasses diets ranging from vegan to Mediterranean and DASH.

2) Adverse.

- These foods included fried potatoes, refined grain desserts, salty snacks, pastries, sweets, high-fat red meats, processed meats, organ meats, fried fish/poultry, sauces, soft drinks, whole fat milk/cheese/yogurt, and butter.

- This could be considered a typical American diet.

3) Neutral.

- These foods included potatoes, refined grains, margarine, chocolate, meal replacements, pickled foods, lean meats, shellfish, eggs, soups, and fruit juices.

- These foods are not the healthiest, but the evidence that they have a negative effect on health disease risk is inconclusive.

The participants were divided into 5 quintiles based on adherence to a plant-centered diet, with quintile 1 having the lowest adherence and quintile 5 having the highest adherence to a plant-centered diet.

The effect of diet on heart disease was measured in two ways:

1) The dietary data from years 0, 7 and 20 were averaged and the effect of average adherence to a plant-centered diet on the risk of developing heart disease by the time the participants were 57 was measured. This is similar to the design of most other studies looking at the effect of diet and heart disease.

2) The effect of an improvement in adherence to a plant-centered diet between ages of 32 and 45 on the risk of developing heart disease by age 57 was also measured. This is what makes this study unique. Basically, the investigators were asking if you could eat a bad diet for 30 years or more and still reduce your risk of heart disease by switching to a good diet by the age of 45. That is the question that millions of American are asking themselves right now.

Is It Too Late To Change Your Diet?

As I described above this study asked two distinct questions:

1) What effect does your habitual diet have on your risk of developing heart disease?

For this portion of the study, the investigators averaged the dietary data collected in years 0, 7, and 20 of the study and ranked the participants diet from 1 to 5 based on their adherence to a plant-centered diet. When they compared the group with best adherence (group 5) with the group with worst adherence (group 1):

- Adherence to a plant-centered diet reduced their risk of developing heart disease by 48%.

- This is consistent with previous studies looking at the beneficial effects of plant-centered diets on heart disease.

2) What effect does changing your diet from bad to good when you are in your 30s or 40s have on your risk of developing heart disease?

For this portion of the study, the investigators compared the dietary data collected at years 7 and 20 (corresponding to average ages 32 and 45 for the participants) and ranked the participants from 1 to 5 based on improved adherence to a plant-centered diet. When they compared the group with best improvement in adherence (group 5) with the group with worst improvement in adherence (group 1):

- Improved adherence to a plant-centered diet reduced the risk of developing heart disease by 39%.

- This answers the questions I posed at the beginning of this article. In short, it is never too late to change your diet for the better.

The authors concluded, “In summary, our study shows that long-term consumption of a nutritionally rich plant-centered diet is associated with a lower risk of heart disease. Furthermore, increased [adherence to a] plant-centered diet in young adulthood is associated with a lower subsequent risk of heart disease throughout middle age, independent of the earlier diet quality” [In short, they are saying that changing to a more plant-centered diet in your 30s and 40s reduces your risk of heart disease.]

You Can Improve Your Health At Any Age

I titled this section, “You Can Improve Your Health At Any Age” for a reason. I wanted to make the point that it is never too late to change your diet, and your health, for the better.

Yes, I realize that the study I described above only shows:

The effect of changing to a more plant-centered diet in your 30s and 40s.

The benefit of changing to a more plant-centered diet on heart disease outcomes.

However, we have ample evidence that changing to a more plant-based diet at any age is likely to reduce the risk of many diseases. For example:

Multiple studies show that habitual consumption of a plant-centered diet is associated with a lower risk of heart disease, high blood pressure, diabetes, inflammatory diseases, some cancers, and premature death for people in their 60s, 70s, and beyond. For example (AJ Glenn et al, Journal of the American Heart Association, 10:e021515, 2021).

There are multiple reports in the literature of people in their 60s and 70s who had a health scare, changed to a more plant-centered diet, and dramatically improved their health.

While neither type of study can be considered definitive by itself, together they suggest it is never too late to change your diet for the better.

But what changes should you make? As I said above, anything from Vegan to Mediterranean or DASH fits the definition of a plant-centered diet (something I have previously referred to as a primarily plant-based diet).

You could choose the plant-centered diet that best fits your preferences and lifestyle and read books or go online to find details and recipes that will help you transition to that diet…or you could simply:

Eat more fruit, avocado, beans/legumes, green vegetables, yellow vegetables, tomatoes, other vegetables, nuts and seeds, soy products, whole grains, vegetable oil, fatty fish, lean fish, poultry, moderate alcohol, coffee, tea, and low-fat milk/cheese/yogurt.

Eat less fried potatoes, refined grain desserts, salty snacks, pastries, sweets, high-fat red meats, processed meats, organ meats, fried fish/poultry, sauces, soft drinks, whole fat milk/cheese/yogurt, and butter.

Eat these foods in moderation: potatoes, refined grains, margarine, chocolate, meal replacements, pickled foods, lean meats, shellfish, eggs, soups, and fruit juices.

The Bottom Line

If you are like most Americans, you know your diet is unhealthy. But it is the diet you grew up with. It’s the diet you love. So, you keep eating it anyway.

Then you have a wake-up call. You find yourself in your doctor’s office, and your doctor is advising you to change your diet. But giving up the diet you love is difficult, and you wonder if it is worth it. Can you really improve your health significantly by changing your diet now, or is it too late? Has the damage already been done?

Fortunately, a recent study has answered these questions. This study started with people in their mid-20s. And it looked at whether changing their diet from bad to good in their 30s and 40s had any effect on their health in their 50s and 60s. This is what the study found.

Improved adherence to a plant-centered diet in their 30s and 40s reduced their risk of developing heart disease in their 50s and 60s by 39%.

While this study was very specific in terms of age and disease, I have discussed in the article above why changing to a more plant-based diet at any age is likely to reduce your risk of multiple diseases. In short, it is never too late to change your diet, and your health, for the better.

For more details about this study and how to change your diet for the better, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.