Which Diets Are Heart Healthy?

Which Diet Is Best For You?

Author: Dr. Stephen Chaney 

strong heartThe top 3 claims the advocates of every popular diet make are:

  • It will help you lose weight.
  • It reduces your risk of diabetes.
  • It reduces your risk of heart disease.

The truth is any restrictive diet helps you lose weight. And when you lose weight, you improve blood sugar control. Which, of course, reduces your risk of developing diabetes.

But what about heart disease? Which diets are heart healthy? When it comes to heart disease the claims of diet advocates are often misleading. That’s because the studies these advocates use to support their claims are often poor quality studies. Many of these studies:

  • Look at markers of heart disease risk rather than heart disease outcomes. Markers like LDL cholesterol, triglycerides, c-reactive protein, etc. are only able to predict possible heart disease outcomes. To really know which diets are heart healthy you have to measure actual heart disease outcomes such as heart attacks, stroke, and cardiovascular deaths.
  • Are too short to provide meaningful results. Many of these studies last only a few weeks. You need much longer to measure heart disease outcomes.
  • Are too small to provide statistically significant results. You need thousands of subjects to be sure the results you are seeing are statistically significant.
  • Have not been confirmed by other studies. The Dr. Strangeloves of the world like to “cherry pick” the studies that support the effectiveness of their favorite diet. Objective scientists know that any individual study can be wrong. So, they look for consensus conclusions from multiple studies.

A recent study (G Karam et al, British Medical Journal, 380: e072003, 2023) avoided all those pitfalls. The investigators conducted a meta-analysis of 40 high-quality clinical studies with 35,548 participants to answer the question, “Which diets are heart healthy?”

How Was The Study Done?

Clinical StudyThe authors started by searching all major databases of clinical studies for studies published on the effect of diets on heart disease outcomes through September 2021.

They then performed a meta-analysis of the data from all studies that:

  • Compared the effect of a particular diet to minimal dietary intervention (defined as not receiving any advice or receiving dietary information such as brochures or brief advice from their clinician with little or no follow-up).
  • Looked at heart disease outcomes such as all cause mortality, cardiovascular mortality, non-fatal heart attacks, stroke, and others.
  • Lasted for at least 9 months (average duration = 3 years).
  • Were high-quality studies.

Using these criteria:

  • They identified 40 studies with 35,548 participants for inclusion in their meta-analysis.
    • From those 40 studies, they identified 7 diet types that met their inclusion criteria (low fat (18 studies), Mediterranean (12 studies), very low fat (6 studies), modified fat (substituting healthy fats for unhealthy fats rather than decreasing fats, 4 studies), combined low fat and low sodium (3 studies), Ornish (3 studies), Pritikin (1 study).

One weakness of meta-analyses is that the design of the studies included in the meta-analysis is often different. Sometimes they don’t fit together well. So, while the individual studies are high-quality, a combination of all the studies can lead to a conclusion that is low quality or moderate quality.

Finally, the data were corrected for confounding factors such as obesity, exercise, smoking, and medication use.

Which Diets Are Heart Healthy?

Now that you understand the study design, we are ready to answer the question, “Which diets are heart healthy?” Here is what this study found:

Compared to minimal intervention,

  • The Mediterranean diet decreased all cause mortality by 28%, cardiovascular mortality by 45%, stroke by 35%, and non-fatal heart attacks by 52%.
  • Low fat diets decreased all cause mortality by 16% and non-fatal heart attacks by 23%. The effect of low fat diets on cardiovascular mortality and stroke was not statistically significant in this meta-analysis.
    • For both the Mediterranean and low fat diets, the heart health benefits were significantly better for patients who were at high risk of heart disease upon entry into the study.
    • The evidence supporting the heart health benefits for both diets was considered moderate quality evidence for this meta-analysis. [Remember that the quality of any conclusion in a meta-analysis is based on both the quality of evidence of the individual studies plus how well the studies fit together in the meta-analysis.]
  • While the percentage of risk reduction appears to be different for the Mediterranean and low fat diets, the effect of the two diets on heart health was not considered significantly different in this study.
  • The other 5 diets provided little, or no benefit, compared to the minimal intervention control based on low to moderate quality evidence.

The authors concluded, “This network meta-analysis found that Mediterranean and low fat dietary programs probably reduce the risk of mortality and non-fatal myocardial infarction [heart attacks] in people at increased cardiovascular risk. Mediterranean dietary programs are also likely to reduce the risk of stroke. Generally, other dietary programs were not superior to minimal intervention.”

Which Diet Is Best For You?

confusionThe fact that this study found both the Mediterranean diet and low fat diets to be heart healthy is not surprising. Numerous individual studies have found these diets to be heart healthy. So, it is not surprising when the individual studies were combined in a meta-analysis, the meta-analysis also concluded they were heart healthy. However, there are two important points I would like to make.

  • The diets used in these studies were designed by trained dietitians. That means the low fat studies did not use Big Food, Inc’s version of the low fat diet in which fatty foods are replaced with highly processed foods. In these studies, fatty foods were most likely replaced with whole or minimally processed foods from all 5 food groups.
  • The Mediterranean diet is probably the most studied of current popular diets. From these studies we know the Mediterranean diet improves brain health, gut health, and reduces cancer risk.

As for the other 5 diets (very low fat, modified fat, low fat and low sodium, Ornish, and Pritikin), I would say the jury is out. There is some evidence that these diets may be heart healthy. But very few of these studies were good enough to be included in this meta-analysis. Clearly, more high-quality studies are needed.

Finally, you might be wondering why other popular diets such as paleo, low carb, and very low carb (Atkins, keto, and others) were left out of this analysis. All I can say is that it wasn’t by design.

The authors did not select the 7 diets described in this study and then search for studies testing their effectiveness. They searched for all studies describing the effect of diets on heart health. Once they identified 40 high-quality studies, they grouped the diets into 7 diet categories.

I can only conclude there were no high-quality studies of paleo, low carb, or very low carb diets that met the criteria for inclusion in this meta-analysis. The criteria were:

  • The effect of diet on heart health must be compared to a control group that received no or minimal dietary advice.
  • The study must measure heart disease outcomes such as all cause mortality, cardiovascular mortality, non-fatal heart attacks, and stroke.
  • The study must last at least 9 months.
  • The study must be high-quality.

Until these kinds of studies are done, we have no idea whether these diets are heart healthy or not.

So, what’s the takeaway for you? Which diet is best for you? Both low fat diets and the Mediterranean diet are heart healthy provided the low fat diet consists of primarily whole or minimally processed foods. Which of these two diets is best for you depends on your food preferences.

The Bottom Line 

Many of you may have been warned by your doctor that your heart health is not what it should be. Others may be concerned because you have a family history of heart disease. You want to know which diets are heart healthy.

Fortunately, a recent study answered that question. The authors performed a meta-analysis of 40 high-quality studies that compared the effect of various diets with the effect of minimal dietary intervention (doctors’ advice or diet brochure) on heart disease outcomes.

From this study they concluded that both low fat diets and the Mediterranean diet probably reduce mortality and the risk of non-fatal heart attacks, and that the Mediterranean diet likely reduces stroke risk.

Other diets studied had no significant effect on heart health in this study. That does not necessarily mean they are ineffective. But it does mean that more high-quality studies are needed before we can evaluate their effect on heart health.

So, what’s the bottom line for you? Both low fat diets and the Mediterranean diet are heart healthy provided the low fat diet consists of primarily whole or minimally processed foods Which of these two diets is best for you depends on your food preferences.

For more information on this study, 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.

___________________________________________________________________________

My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Is Whole Fat Dairy Healthy?

Is It Dairy Or Diet?

Author: Dr. Stephen Chaney 

CheesesFor years we have been told to select low fat dairy foods. But recent headlines claim, “That’s nonsense. Whole fat dairy foods are healthy.” Are those headlines true?

In previous issues of “Health Tips From the Professor” I have kept you abreast of recent studies suggesting that whole fat dairy foods may not be as bad for us as we thought. I also cautioned you that the headlines may not have accurately represented the studies they described.

Headlines have to be simple. But truth is often more nuanced. If we believed the current headlines, we might be asking ourselves questions like, “Should we ditch the current health guidelines recommending low-fat dairy foods? Are foods like ice cream, sour cream, and cheddar cheese actually be good for us?

To answer these questions, I will look at the study (A Mente et al, European Heart Journal, 44, 2560-2579, 2023) behind the current headlines and put the study into perspective.

Spoiler alert: If I could summarize the study findings in two sentences, they would be, “Whole fat dairy can be part of a healthy diet. But can it be part of an unhealthy diet?”

Stay tuned. I will discuss the science behind that statement below.

How Was This Study Done?

clinical studyThis study started with data collected from the Prospective Urban Rural Epidemiology (PURE) study. The PURE study is an ongoing study correlating diet, lifestyle, and environmental effects on health outcomes. It has enrolled 166,762 individuals, age 35-70, from 21 low-, middle-, and high-income countries on 5 continents.

Habitual food intake was determined using country-specific food frequency questionnaires at the time participants joined the study. Participants (166,762) from the PURE study who had complete dietary information were included in this study and were followed for an average of 9.3 years.

Based on preliminary analysis of data from the PURE study, the authors developed their version of a healthy diet, which they call the PURE diet. Like most other healthy diets, the PURE diet emphasizes fruits, vegetables, legumes, nuts, and fish. However:

  • Based on studies suggesting that whole fat dairy foods can be part of a healthy diet, the PURE diet includes whole fat dairy foods.

This is different from most other healthy diet recommendations.

They went on to develop what they referred to as the PURE healthy diet score by:

  • Determining the median intake for each of the 6 food groups included in their PURE diet (fruits, vegetables, legumes, nuts, fish, and whole fat dairy).
  • Assigning each participant in the study a score of 0 or 1 depending on whether their intake for that food group was below or above the median intake.
  • Adding up the points. Since 6 food groups were included in the PURE diet, this means that each participant in the study was assigned a PURE diet score ranging from 0-6.

Once they had developed a PURE diet score, they expanded their data by including five additional large independent studies that included people from 70 countries. The combined data from all six studies amounted to 245,597 people from 80 countries. Of the people included in the data analysis:

  • 21% came from high income countries.
  • 60% came from middle income countries.
  • 19% came from low-income countries.

This is very similar to the global population distribution. This is a strength of this study because it allowed them to ask whether the PURE diet score worked as well in low-income countries as in high-income countries.

Finally, they correlated the PURE diet score with outcomes like all-cause mortality, heart attack, and stroke.

Is Whole Fat Dairy Healthy?

QuestionsThe authors of this study divided the participants of all 6 studies into quintiles based on their PURE diet score and compared those in the highest quintile (PURE score of ≥ 5) with those in the lowest quintile (PURE score of ≤ 1).

The people in the highest quintile were eating on average 5 servings/day of fruits and vegetables, 0.5 servings/day of legumes, 1.2 servings/day of nuts, 0.3 servings/day of fish, 2 servings/day of dairy (of which 1.4 servings/day was whole fat dairy), 0.5 servings/day of unprocessed red meat, and 0.3 servings/day of poultry.

 

The people in the lowest quintile ate significantly less fruits, vegetables, nuts, fish, and dairy; and slightly less legumes, unprocessed red meat, and poultry than those in the highest quintile.

However, they consumed significantly more refined wheat foods and white rice. This study did not track consumption of highly processed foods, but the high consumption of white flour leads me to suspect they ate a lot more highly processed food.

With that in mind, when the authors compared people with the highest PURE diet scores to those with the lowest PURE diet scores:

  • All-cause mortality was reduced by 30%.
  • Cardiovascular disease was reduced by 18%.
  • Heart attacks were reduced by 14%.
  • Strokes were reduced by 19%.
  • The PURE healthy eating score was slightly better at predicting health outcomes than the Mediterranean, DASH, and HEI (Healthy Eating Index) scores. But the differences were small. So, I still recommend choosing the healthy diet that best fits your preferred foods and your lifestyle.
  • The PURE healthy eating score was significantly better at predicting health outcomes than the Planetary diet score. I will discuss the nutritional inadequacy of “sustainable diets” like the Planetary diet in next week’s “Health Tips From the Professor” article.

Because of the size and design of this study, they were able to make three interesting observations.

  1. The PURE, Mediterranean, DASH, and HEI diet scores were predictive of health outcomes in every country across the globe. You no longer have to wonder if what works in the United States will work in low-income countries and in countries with very different food preferences. Previous studies have not been able to make that claim.

2) You don’t have to be perfect.

    • A 20% increase (one quintile) in PURE score was associated with a 6% lower risk of major cardiovascular events and an 8% lower risk of mortality. In other words, even small improvements in your diet may improve your health outcomes.
    • The health benefits of the PURE diet started to plateau at a score of 3 (with 6 being the highest score). The authors concluded that most of the health benefits were associated with a modestly higher consumption of healthy foods compared to little or no consumption of healthy foods.

Simply put, that means the health benefits gained by going from a moderately healthy diet to a very healthy diet are not as great as the health benefits gained by going from a poor diet to a moderately healthy diet.

[Note: There are still improvements in health outcomes when you go from a moderately healthy diet to a very healthy diet.  My recommendation: “You don’t need to achieve perfection, but you shouldn’t accept mediocrity”.]

3) The PURE diet score was more predictive of health outcomes in some countries than in others.

    • The PURE diet score was more predictive of health outcomes in low-income countries. The authors felt that was because low-income countries started with average PURE scores of 2.1, whereas higher-income countries started with average PURE scores of 3.5.

The authors felt this was another example getting more “bang for the buck” by going from a poor diet to a moderately healthy diet than from a moderately healthy diet to a very healthy diet. (Remember, the health benefits associated with improving PURE diet scores start to plateau at a PURE score of 3.

    • The difference in benefits for low-income countries compared to high-income countries was observed for the Mediterranean, DASH, and HEI diet scores. So, it is probably safe to say for any healthy diet you don’t need to be perfect. You just need to be better.

The authors concluded, “A diet composed of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole fat dairy is associated with a lower risk of cardiovascular disease and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.”

Is It Dairy Or Diet?

CheesesThe headlines are telling us that recommendations to choose low-fat dairy products are out of date. They say there is no reason to fear whole fat dairy foods. They are good for you. Bring on the ice cream, sour cream, cream cheese, and high fat hard cheeses!

As usual, there is a kernel of truth in the headlines, but headlines have to be simple. And the latest headlines are an oversimplification of what the studies actually show. Let me provide perspective to the headlines by asking two questions.

#1: Is it dairy or diet? A major weakness of this and similar studies is that they fail to consider diet context. What do I mean by that? Let’s dig a little deeper into this study.

  • Let’s start with a description of the PURE diet. It is a diet that emphasizes fruits, vegetables, legumes, nuts, and fish. In other words, it is a primarily plant-based diet.
  • Although the authors keep referring to the diet as one that includes whole fat dairy. It would be more accurate to say that it includes dairy, which was 30% low-fat and 70% whole fat.
  • The authors said that removal of any one food group from this combination reduced the predictive power of the PURE diet. In other words, the beneficial effect of 70% whole fat dairy is best seen in the context of a primarily plant-based diet.
  • The PURE diet was most effective at predicting health outcomes in low-income countries where a significant percent of the population consumes a primarily plant-based diet because meats are expensive.

So, a more accurate description of this study would be it shows that a mixture of low-fat and whole-fat dairy foods are a healthy addition to a primarily plant-based diet. But that is too complicated for a headline.

#2: If whole fat dairy can be part of a healthy diet, can it also be part of an unhealthy diet?

To answer that question let’s compare the potential effects of whole fat dairy on a primarily plant-based diet compared to the typical American or European diet.

  • Milk and other dairy foods are excellent sources of calcium, vitamin B12, and iodine and good sources of protein, vitamin D, choline, zinc, and selenium – nutrients that are often low or missing in plant-based diet. And this is true whether the dairy foods are low-fat or whole fat.
  • Primarily plant-based diets tend to be low in saturated fat, so the potential negative effects of adding a small amount of saturated fat to the diet may be outweighed by the beneficial effects of the nutrients dairy foods provide.

On the other hand,

  • The typical American or European diet provides plenty of protein and vitamin B12 and significantly more choline, vitamin D, iodine, and zinc than a plant-based diet. The added nutrients from adding dairy foods to this kind of diet is still beneficial, but the benefits are not as great as adding dairy foods to a primarily plant-based diet.
  • If you read the American Heart Association statement on saturated fats, it does not say that any amount of saturated fat is bad for you. In fact, small amounts of saturated fats play some beneficial roles in our bodies. The American Heart Association says, “Eating too much saturated fat can raise the level of LDL cholesterol in your blood…[which] increases your risk of heart disease and stroke.”
  • Here is where the problem lies. The typical American or European diet already contains too much saturated fat. Whole fat dairy just adds to that excess.

So, the most accurate description of this study would be it shows that a mixture of low-fat and whole-fat dairy foods are a healthy addition to a primarily plant-based diet but may not be a healthy addition to the typical American diet. But that is way too complicated for a headline.

You are probably wondering what this means for you. Here are my recommendations.

If you eat like most Americans, you should continue to follow the current health guidelines to choose low-fat dairy foods.

If you happen to be among the few Americans who eat a primarily plant-based diet, you will probably benefit by adding a mixture of low-fat and whole fat dairy foods to your diet.

The Bottom Line 

Once again, the headlines are telling us that recommendations to choose low-fat dairy products are out of date. The articles say there is no reason to fear whole fat dairy foods. They are good for you. Bring on the ice cream, sour cream, cream cheese, and high fat hard cheeses!

As usual, there is a kernel of truth in the headlines, but headlines have to be simple. And the latest headlines are an oversimplification of what the studies actually show. In this post I looked at the study behind the most recent headlines and provided perspective to the headlines by asking two questions.

#1: Is it dairy or diet? A major weakness of this and similar studies is that they fail to consider diet context.

When you consider diet context a more accurate description of this study would be it shows that a mixture of low-fat and whole-fat dairy foods are a healthy addition to a primarily plant-based diet. But that is too complicated for a headline.

#2: If whole fat dairy can be part of a healthy diet, can it also be part of an unhealthy diet?

When you consider that question the most accurate description of this study would be it shows that a mixture of low-fat and whole-fat dairy foods are a healthy addition to a primarily plant-based diet but may not be a healthy addition to the typical American diet. But that is way too complicated for a headline.

You are probably wondering what this means for you. Here are my recommendations.

If you eat like most Americans, you should continue to follow the current health guidelines to choose low-fat dairy foods.

If you happen to be among the few Americans who eat a primarily plant-based diet, you will probably benefit by adding a mixture of low-fat and whole fat dairy foods to your diet.

For more information on this study, and the science behind my summary of the study, 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.

_________________________________________________________________________

My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Are All Carbs Bad?

Are Low Carb Enthusiasts Right About The Dangers Of Carbohydrates?

Author: Dr. Stephen Chaney 

Low carb enthusiasts have been on the warpath against carbohydrates for years.

Almost everyone agrees that sugar-sweetened sodas and highly processed, refined foods with added sugar are bad for us. But low carb enthusiasts claim that we should also avoid fruits, grains, and starchy vegetables. Have they gone too far?

Several recent studies suggest they have. For example, both association studies and randomized controlled studies suggest that total carbohydrate intake is neither harmful nor beneficial for heart health.

In addition, recent studies suggest that free sugar intake is associated with both elevated triglyceride levels and an increase in heart disease risk.

But those studies have mostly looked at free sugar intake from sugar-sweetened sodas. The authors of this study (RK Kelley et al, BMC Medicine, 21:34, 2023) decided to look more carefully at the effect of all free sugars and other types of carbohydrates on triglyceride levels and heart disease risk.

How Was This Study Done?

clinical studyThe 110,497 people chosen for this study were a subgroup of participants in the UK Biobank Study, a large, long-term study looking at the contributions of genetic predisposition and environmental exposure (including diet) to the development of disease in England, Scotland, and Wales.

The participants in this study were aged between 37 and 73 (average age = 56) on enrollment and were followed for an average of 9.4 years. None of them had a history of heart disease or diabetes or were taking diabetic medications at the time of enrollment.

During the 9.4-year follow-up, five 24-hour dietary recalls were performed, so that usual dietary intake could be measured rather than dietary intake at a single time point. The people in this study participated in an average of 2.9 diet surveys, and none of them had less than two diet surveys.

The averaged data from the dietary recalls were analyzed for the amount and kinds of carbohydrate in the diet. With respect to the types of carbohydrate, the following definitions would be useful.

  • The term free sugars includes all monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and unsweetened fruit juices.
  • The term non-free sugars includes all sugars not in the free sugar category, mostly sugars naturally occurring in fruits, vegetables, and dairy products.
  • The term refined grains includes white bread, white pasta, white rice, most crackers and cereals, pizza, and grain dishes with added fat.
  • The term whole grains includes wholegrain bread, wholegrain pasta, brown rice, bran cereal, wholegrain cereals, oat cereal, and muesli.

Finally, the study looked at the association of total carbohydrate and each class of carbohydrate defined above with all heart disease, heart attacks, stroke, and triglyceride levels.

Are All Carbs Bad?

Question MarkThe study looked at total carbohydrate intake, free sugar intake, and fiber intake. In each case, the study divided the participants into quartiles and compared those in the highest quartile with those in the lowest quartile.

Using this criterion:

  • Total carbohydrate intake was not associated with any cardiovascular outcome measured (total heart disease risk, heart attack risk, and stroke risk).
  • Free sugar intake was positively associated with all cardiovascular outcomes measured. Each 5% increase in caloric intake from free sugars was associated with a:
    • 7% increase in total heart disease risk.
    • 6% increase in heart attack risk.
    • 10% increase in stroke risk.
    • 3% increase in triglyceride levels.
  • Fiber intake was inversely associated with total heart disease risk. Specifically, each 5 gram/day increase in fiber was associated with a:
    • 4% decrease in total heart disease risk.

The investigators also looked at the effect of replacing less healthy carbohydrates with healthier carbohydrates. They found that:

  • Replacing 5% of caloric intake from refined grains with whole grains reduced both total heart disease risk and stroke risk by 6%.
  • Replacing 5% of caloric intake from free sugars (mostly sugar-sweetened beverages, fruit juices, and processed foods with added sugar) with non-free sugars (mostly fruits, vegetables, and dairy products) reduced total heart disease risk by 5% and stroke risk by 9%.

Are Low Carb Enthusiasts Right About The Dangers Of Carbohydrates?

With these data in mind let’s look at the claims of the low-carb enthusiasts.

Claim #1: Carbohydrates raise triglyceride levels. This study shows:

  • This claim is false with respect to total carbohydrate intake and high fiber carbohydrate intake (fruits, vegetables, and whole grains. This study did not measure intake of beans, nuts, and seeds, but they would likely be in the same category).
  • However, this claim is true with respect to foods high in free sugars (sugar-sweetened beverages, fruit juices, and processed foods with added sugar).

Claim #2: Carbohydrates increase heart disease risk. This study shows:

  • That claim is false with respect to total carbohydrate intake and high fiber carbohydrate intake.
  • However, this claim is true with respect to foods high in free sugars.

Claim #3: Carbohydrates cause weight gain [Note: Low carb enthusiasts usually word it differently. Their claim is that eliminating carbohydrates will help you lose weight. But that claim doesn’t make sense unless you believed eating carbohydrates caused you to gain weight.] This study shows:

  • This claim is false with respect to total carbohydrate intake and high fiber carbohydrate intake.
  • Once again, this claim is true with respect to foods high in free sugars.

The data with high fiber carbohydrates was particularly interesting. When the authors compared the group with the highest fiber intake to the group with the lowest fiber intake, the high-fiber group:

  • Consumed 33% more calories per day.
  • But had lower BMI and waste circumference (measures of obesity) than the low-carbohydrate group.

This suggests that you don’t need to starve yourself to lose weight. You just need to eat healthier foods.

And, in case you were wondering, the high fiber group ate:

  • 5 more servings of fruits and vegetables and…
  • 2 more servings of whole grain foods than the low fiber group.

This is consistent with several previous studies showing that diets containing a lot of fruits, vegetables, and whole grains are associated with a healthier weight.

The authors concluded, “Higher free sugar intake was associated with higher cardiovascular disease incidence and higher triglyceride concentrations…Higher fiber intake and replacement of refined grain starch and free sugars with wholegrain starch and non-free sugars, respectively, may be protective for incident heart disease.”

In short, with respect to heart disease, the type, not the amount of dietary carbohydrate is the important risk factor.

What Does This Mean For You?

Questioning WomanForget the low carb “mumbo jumbo”.

  • Carbohydrates aren’t the problem. The wrong kind of carbohydrates are the problem. Fruit juice, sugar-sweetened sodas, and processed foods with added sugar:
    • Increase triglyceride levels.
    • Are associated with weight gain.
    • Increase the risk for heart disease.
  • In other words, they are the villains. They are responsible for the bad effects that low carb enthusiasts ascribe to all carbohydrates.
  • Don’t fear whole fruits, vegetables, dairy, and whole grain foods. They are the good guys.
    • They have minimal effect on triglyceride levels.
    • They are associated with healthier weight.
    • They are associated with a lower risk of heart disease and diabetes.

So, the bottom line for you is simple. Not all carbs are created equal.

  • Your mother was right. Eat your fruits, vegetables, and whole grains.
  • Avoid fruit juice, sodas and other sugar-sweetened beverages, and processed foods with added sugar. [Note: Artificially sweetened beverages are no better than sugar-sweetened beverages, but that’s another story for another day.]

And, if you were wondering why low carb diets appear to work for weight loss, it’s because any restrictive diet works short term. As I have noted previously, keto and vegan diets work equally well for short-term weight loss.

The Bottom Line 

Low carb enthusiasts have been telling us for years to avoid all carbohydrates (including fruits, starchy vegetables, and whole grains) because carbohydrates:

  • Increase triglyceride levels.
  • Cause weight gain.
  • Increase our risk for heart disease.

A recent study has shown that these claims are only true for some carbohydrates, namely fruit juices, sodas and other sugar-sweetened beverages, and processed foods with added sugar.

Whole fruits, vegetables, and whole grain foods have the opposite effect. They:

  • Have a minimal effect on triglyceride levels.
  • Are associated with a healthier weight.
  • Are associated with a lower risk of heart disease and diabetes.

So, forget the low carb “mumbo jumbo” and be sure to eat your fruits, vegetables, and whole grains.

For more information 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.

___________________________________________________________________________

My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Is HDL Good For Your Heart?

Is Everything You Knew About HDL Wrong?

Author: Dr. Stephen Chaney 

HDL CHolesterolIn last week’s “Health Tips From the Professor” I talked about one of the greatest strengths of the scientific method – namely that investigators constantly challenge, and occasionally disprove, existing paradigms. That allows us to discard old models of how things work and replace them with better ones.

Last week I shared a study that disproved the paradigm that low to moderate alcohol consumption is healthier than total abstinence. This week I share several studies that challenge the belief that HDL cholesterol is good for your heart.

The belief that HDL is good for your heart has all the hallmarks of a classic paradigm.

  • It is supported by multiple clinical studies.
  • Elaborate metabolic explanations have been proposed to support the paradigm.
  • It is the official position of most medical societies, scientific organizations, and health information sites on the web.
  • It is the recommendation of most health professionals.
  • It has been repeated so often by so many trusted sources that everyone assumes it must be true.

Once we accept the HDL/heart health paradigm as true, we can construct other hypotheses on that foundation. For example:

  • Raising your HDL levels naturally takes effort. Pharmaceutical companies have been pursuing the “magic pill” that raises HDL levels without any effort on your part.
  • Low carb diets like the Keto and Paleo diets are high in saturated fat. The low carb enthusiasts claim this is a good thing because saturated fat raises HDL levels, and HDL is good for your heart.

But what if the underlying HDL/heart health paradigm weren’t true? These hypotheses would be like the parable of a house built on a foundation of sand. The paradigm will be washed away as soon as it is critically tested.

So, let’s look at experiments that have challenged the HDL/heart health paradigm.

Do Drugs That Increase HDL Levels Work?

The first hint that the HDL/heart health paradigm might be faulty happened when a pharmaceutical company developed a drug that selectively increased HDL levels.

The drug company thought they had found the goose that laid golden eggs. Just imagine. People wouldn’t have to lose weight, exercise, or change their diet. They could simply take a pill and dramatically decrease their heart disease risk. A drug like that would be worth $billions.

The problem was that when they tested their drug (torcetrapib) in clinical trials, it had absolutely no effect on heart disease outcomes (AR Tall et al, Atherosclerosis, Thrombosis, and Vascular Biology 27:257-260, 2007).

The pharmaceutical company couldn’t believe it. Raising HDL levels just had to reduce heart disease risk. They concluded they didn’t have the right drug, and they continued to work on developing new drugs.

That was 16 years ago, and no HDL-increasing drug has made it to market. Have they just not found the right drug, or does this mean the HDL/heart health paradigm is incorrect?

Does Saturated Fat Decrease Heart Disease Risk?

Now let’s turn to two claims of low carb enthusiasts.

#1: Saturated fats decrease your risk of heart disease in the context of a low carb diet. I have debunked that claim in several previous issues of “Health Tips From The Professor”. But let me refer you to two articles here – one on saturated fat and heart disease risk and one on low-carb diets.

#2: Saturated fats decrease heart disease risk because they raise HDL levels. This is the one I will address today.

The idea that saturated fats decrease heart disease risk because they raise HDL levels is based on a simplistic concept of HDL particles. The reality is more complex. Several clinical studies have shown:

  • The type of fat determines the property of the HDL particles.
    • When polyunsaturated fats predominate, the HDL particles have an anti-inflammatory effect. When saturated fats predominate, the HDL particles have a pro-inflammatory effect.
  • Anti-inflammatory HDL particles relax the endothelial cells lining our blood vessels. That makes the lining of our blood vessels more pliable, which improves blood flow and reduces blood pressure.
    • Anti-inflammatory HDL particles also help reduce inflammation of the endothelial lining. This is important because an inflamed endothelial lining is more likely to accumulate fatty plaques and to trigger blood clot formation that can lead to heart attacks and strokes.

So, the question becomes, “What good is it to raise HDL levels if you are producing an unhealthy, pro-inflammatory HDL particle that may increase the risk of high blood pressure, heart attacks, and strokes?”

In short, these studies suggest it isn’t enough to just focus on HDL levels. You need to ask what kind of HDL particles you are creating.

Is HDL Good For Your Heart?

strong heartOnce the studies were published showing that…

  • Drug-induced increase of HDL levels without any change in health habits is not sufficient to decrease heart attack risk, and…
  • Not all HDL particles are healthy. There are anti-inflammatory or pro-inflammatory HDL particles, which likely have opposite effects on heart attack risk…

…some people started to question the HDL/heart health paradigm. And one group came up with the perfect study to test the paradigm.

But before I describe the study, I need to review the term “confounding variables”. I described the term and how it affects clinical studies in last week’s article. Here is a brief synopsis:

  • The studies supporting the HDL/heart health paradigm are association studies. Association studies measure the association between a single variable (in this case, increase in HDL levels) and an outcome (in this case, heart disease events, heart disease deaths, and total deaths).
  • Associations need to be corrected for other variables known to affect the same outcome (things like age, gender, smoking, and diabetes would be examples in this case).
  • Confounding variables are variables that also affect the outcome but are unknown or ignored. Thus, they are not used to correct the associations, which can bias the results.

The authors of this study (M Briel et al, BMJ 2009:338.b92) observed that most interventions that increase HDL levels also lower LDL levels. Lowering LDL is known to decrease the risk of heart disease deaths. But this effect had been ignored in most studies looking at the association between HDL and heart disease deaths.

They hypothesized that the change in LDL levels was a confounding variable that had been ignored in previous studies and may have biased the results.Heart Disease Study

To test this hypothesis the authors searched the literature and identified 108 studies with 299,310 participants that:

  • Compared the effect of drugs, omega-3 fatty acids, or diet with either a placebo or usual care.
  • Measured both HDL and LDL levels.
  • Measured reduction in cardiovascular risk.
  • Had a randomized control design.
  • Lasted at least 6 months.

They found that every 10 mg/dl decrease in LDL levels in these studies was responsible for a:

  • 7.1% reduction in heart disease events (both heart disease deaths and non-fatal heart attacks).
  • 7.2% reduction in heart disease deaths.
  • 4.4% reduction in total deaths.

After correcting for the effect of decreased LDL levels on these heart disease outcomes, the increase in HDL levels had no statistically significant effect on any of the outcomes.

The authors concluded, “Available data suggest that simply increasing the amount of circulating HDL cholesterol does not reduce the risk of coronary heart disease events, coronary heart disease deaths, or total deaths. The results support reduction in LDL cholesterol as the primary goal for lipid modifying interventions.”

In other words, this study:

  • Supports the author’s hypothesis that LDL levels were a confounding variable that biased the studies supporting the HDL/heart health paradigm.
  • Concludes that increasing HDL levels has no effect on heart disease outcomes, thus invalidating the HDL/heart health paradigm.

Is Everything You Knew About HDL Wrong?

Peek Behind The CurtainDoes that mean that everything you knew about HDL is wrong? Not exactly. It just means that you need to change your perspective.

Don’t focus on HDL levels. Peek behind the curtain and focus on what’s behind the HDL levels. For example:

  • Losing weight when overweight increases HDL levels. But the decrease in heart disease outcomes is more likely due to weight loss than to the increase in HDL levels.
  • Exercise increases HDL levels. But the decrease in heart disease outcomes is more likely due to exercise than to the increase in HDL levels.
  • Reversing pre-diabetes or type 2 diabetes increases HDL levels. But the decrease in heart disease outcomes is more likely due to the reversal of diabetes than to the increase in HDL levels.
  • High-dose omega-3 fatty acids increase HDL levels. But the decrease in heart disease outcomes is more likely due to the omega-3 fatty acids than to the increase in HDL levels.
  • The Mediterranean diet increases HDL levels. But the decrease in heart disease outcomes is more likely due to the diet than to the increase in HDL levels.

And if you want to go the drug route:

  • Statins and some other heart drugs increase HDL levels, but the reduction in heart disease outcomes is probably due to their effect on LDL levels rather than their effect on HDL levels.

On the other hand:

  • Saturated fats increase HDL levels. But saturated fats increase heart disease risk and create pro-inflammatory HDL particles. So, in this case the increase in HDL levels is not a good omen for your heart.
  • Drugs have been discovered that selectively increase HDL levels. However, there is nothing of value behind this increase in HDL levels, so the drugs have no effect on heart disease outcomes.

The Bottom Line 

In this article I discuss several studies that have challenged the HDL/heart health paradigm – the belief that HDL is good for your heart.

For example, one group of investigators analyzed the studies underlying the HDL/heart health paradigm. They hypothesized that these studies were inaccurate because they failed to account for the effects of LDL levels on heart disease outcomes.

After correcting for the effect of decreased LDL levels on heart disease outcomes in the previous studies, the authors showed that increases in HDL levels had no significant effect on any heart disease outcome.

The authors concluded, “Available data suggest that simply increasing the amount of circulating HDL cholesterol does not reduce the risk of coronary heart disease events, coronary heart disease deaths, or total deaths. The results support reduction in LDL cholesterol as the primary goal for lipid modifying interventions.”

In other words, this study:

  • Supports the author’s hypothesis that LDL levels were a confounding variable that biased the studies supporting the HDL/heart health paradigm.
  • Concludes that increasing HDL levels has no effect on heart disease outcomes, thus invalidating the HDL/heart health paradigm.

Does that mean that everything you knew about HDL is wrong? Not exactly. It just means that you need to change your perspective. Don’t focus on HDL levels. Focus on what’s behind the HDL levels. For more information on that, read the article above.

For more information 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.

____________________________________________________________________________

My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Is Erythritol Bad For Your Heart?

Who Should Be Concerned About Erythritol Intake?

Author: Dr. Stephen Chaney 

Everyone is searching for the perfect sweetener. And if you were in the marketing department of Big Food Inc, the perfect sweetener would be defined as:

  • Natural, meaning that it is found in fruits, vegetables, or other plant foods.
  • Low in calories. Of course, a perfect sweetener would have zero calories because it is not metabolized in our bodies.
  • Low glycemic, meaning that it would have a minimal effect on blood sugar levels. Once again, a perfect sweetener would have zero effect on blood sugar levels.
  • Safe, meaning that it has no adverse effects on our health.

Sugar alcohols appear to meet all these criteria, so they have become the sweetener of choice for lots of highly processed foods. This is especially true for the sugar alcohol, erythritol, since it is currently the least expensive of the sugar alcohols.

So, a recent study (M Witowski et al, Nature Medicine, 2023) suggesting that erythritol might increase the risk of heart disease was quite surprising.

This is the first study to suggest a link between erythritol and heart disease, and it was a flawed study (I will discuss the flaws below).

Reputable scientists don’t put much credence in a weak first study like this one. We generally consider the conclusions of a first study like this one to be an unproven hypothesis at this point.

But we are cautious. There will be many follow-up, better designed studies, to test this hypothesis. Once these studies have been published, the scientific community will look at all the evidence and either issue a warning or conclude that there is no reason for concern.

But that doesn’t stop the Dr. Strangeloves of the world from warning you of the “dangers” of erythritol and telling you to avoid it at all costs.

For that reason, I felt it was appropriate to address this issue. I will:

  • Describe the study and its flaws.
  • Put the study into the broader perspective of what we know about sweeteners.
  • Identify the two population groups who should be most concerned about erythritol.

How Was The Study Done And What Did It Show?

This study can be divided into three parts.

heart disease#1: An Association Between Erythritol Blood Levels And Heart Disease.

There were three separate experiments included in this section of the study. In each experiment patients were recruited after visiting cardiac clinics for diagnostic procedures. The average age of these patients was 67 and 45% of them already had experienced a non-fatal heart attack prior to the study. In other words, these were all older patients with pre-existing heart disease who were at high risk of heart attack or stroke in the near future.

The first study was a metabolomic study. In simple terms this means that high-tech equipment and computing were used to measure hundreds of metabolites in the blood of the patients and, in this case, correlate each of them with the occurrence of heart attacks and strokes over the next three years.

  • This study identified 16 sugar alcohols and related metabolites in the blood of these patients that were associated with an increased risk of heart attack and stroke. (I will discuss the significance of this observation in more detail later.)

Because erythritol was among the top 6 compounds in terms of association with increased heart attack and stroke risk, and erythritol is the most commonly used sugar alcohol in processed foods, the next two studies focused on the association between blood levels of erythritol and heart attack/stroke risk. Their results were predictable.

  • High blood levels of erythritol were associated with an increased risk of heart attack and stroke over the next three years.

Flaws In This Portion Of The Study:thumbs down symbol

  • As the authors of the study pointed out, these studies were done with older patients with pre-existing heart disease who were at high risk of heart attack or stroke. They acknowledged that it is not known whether these associations exist with younger, healthier patients.
  • As the authors also pointed out, these are associations. They do not prove cause and effect. In particular, the studies did not measure the diet, exercise habits, and other lifestyle factors of these patients that may have contributed to their increased risk of heart attack and stroke.
  • When you look closely at the data, it is clear that the association is only seen at the highest blood levels of erythritol. Specifically, the blood levels of erythritol in these patients were divided into quartiles. The risk of heart attack and stroke in the first three quartiles (low to moderate blood levels of erythritol) were identical to the control. However, the fourth quartile (highest blood levels of erythritol) was associated with a dramatically increased risk of heart attack and stroke. That raises three important questions:
    • “How much erythritol were patients in the fourth quartile consuming?”
      • The authors did not look at dietary intake of erythritol but did note a previous study estimated that Americans consume up to 30 grams of erythritol a day.
    • 30 grams of erythritol a day is a huge amount of erythritol. Where does that erythritol come from?
      • Much of it comes from erythritol-containing highly processed foods like zero calorie sugar substitutes (either erythritol alone or erythritol mixed with artificial sweeteners to improve the taste); reduced- and low calorie carbonated and non-carbonated beverages; hard candy and cough drops, cookies, cakes, pastries, and bars; puddings and pie fillings; soft candies; syrups and toppings; ready to eat cereals; fruit novelty snacks; and frozen desserts.
      • But it is also found in foods you might not suspect, such as plant-based “milk” substitutes; chocolate and flavored milks; barbecue and tomato sauce, fruit-based smoothies, the syrup used in canned fruits, yoghurt; low calorie salad dressings; and salty snacks.
      • In other words, the only way anyone can consume 30 grams of erythritol in a day is to consume large quantities of erythritol-containing highly processed foods (I will discuss the significance of this observation later).
    • “What else was different about patients in the fourth quartile?”
      • When you look carefully at the data, the patients in the fourth quartile were significantly older, with a higher incidence of diabetes, pre-existing coronary artery disease, previous non-fatal heart attacks, congestive heart failure, and greater triglycerides – all of which significantly increase their risk of heart attack and stroke.

#2: Mechanistic Studies:

Next the authors did in vitro and animal studies looking at the effect of high levels of erythritol on blood clotting.

  • These studies showed that high levels of erythritol promoted blood clotting both in vitro and in mice. The authors concluded that these studies provided a plausible mechanism for a link between high erythritol blood levels and increased risk of heart attack and stroke.

Flaws In This Portion Of The Study:thumbs down symbol

  • Other critics have pointed out that the assays used were not accurate models of blood clotting in humans. This particular critique is beyond my expertise, so I won’t comment further. However:
    • As someone who was involved in cancer drug development for over 30 years, I know that in vitro and animal models are poor indicators of how things work in humans.
    • And as a biochemist, I have two concerns:
      • The authors provided no mechanistic rationale for why erythritol would enhance blood clotting.
      • The authors made no effort to show that the effect of erythritol was unique. Would high levels of other sugar alcohols or other naturally occurring sugars have the same effect on blood clotting in their assays? We don’t know.

#3: Blood Levels Of Erythritol After Oral Intake.

Finally, the authors gave subjects 30 grams of erythritol and measured blood levels over the next several days.

  • This experiment showed that very high blood levels of erythritol were attained and maintained for at least two days before gradually decreasing to baseline. The authors concluded this experiment showed that it was feasible to attain and maintain high blood levels of erythritol for several days following a single ingestion of 30 grams of erythritol.

Flaws In This Portion Of The Study:thumbs down symbol

  • I have already pointed out that 30 grams per day is a huge amount of erythritol. However, erythritol in the diet will come from a variety of foods, some of which will contain components (fiber etc.) that slow the absorption of erythritol.
  • In contrast, the subjects in this experiment were given 300 ml of liquid containing 30 grams of erythritol and told to drink it in two minutes!
  • In other words, these subjects were consuming 30 grams of erythritol in 2 minutes rather than 24 hours, and they were consuming it in the most easily absorbable form. For a study like this, that makes the effective dose orders of magnitude greater than the amount of erythritol that anyone consumes from their diet over a 24-hour period. The study design was completely unrealistic.

Is Erythritol Bad For Your Heart?

Question MarkAs described above, this is the first study to suggest an association between erythritol and heart disease, and it was a highly flawed study.

It is also important to know that erythritol is not an artificial sweetener. It is found naturally in foods like grapes, peaches, pears, watermelons, and mushrooms. It is also found in some fermented foods like cheese, soy sauce, beer, sake, and wine.

It is also a byproduct of normal human metabolism, so we always have some of it circulating in our bloodstream. Our body knows how to handle low to moderate intakes of erythritol.

However, to help you really understand what this study means, I need to put it into the context of other studies. I will do this in story form (You will find more details about these studies in my book “Slaying The Food Myths”).

First, let’s look at highly processed food consumption:

  • Multiple recent studies have shown that high consumption of highly processed food is associated with increased risk of obesity, diabetes, heart disease, and premature death. We don’t know what it is about highly processed food consumption that is responsible for the increased risk, but it is unlikely to be just one thing.
  • As I pointed out above, the only way to achieve the high blood levels of erythritol associated with increased heart disease risk is to consume large quantities of erythritol-containing highly processed foods.

Next, let’s follow the history of sweeteners in highly processed foods.

  • When I was a young man, sucrose (table sugar) was added to most highly processed foods. Sucrose is foundsugar cubes naturally in many fruits and vegetables. Small to moderate intake of sucrose in unprocessed and minimally processed foods posed no problem. However, large intakes of sugar in highly processed foods were found to increase the risk of obesity, diabetes, heart disease, and premature death.
  • At that point, sucrose became a “sugar villain”, and Big Food, Inc substituted fructose and high fructose corn syrup (a mixture of fructose and glucose) for sugar in their highly processed foods. As with sucrose, fructose is found naturally in many foods, and small to moderate intakes of fructose and high fructose corn syrup posed no health risks. However, large intakes of fructose and high fructose corn syrup in highly processed foods were found to increase the risk of obesity, diabetes, heart disease, and premature death.
  • Fructose and high fructose corn syrup then became the sugar villains. And because high fructose corn syrup is chemically and biologically indistinguishable from natural sugars like honey, date sugar, coconut sugar, it is likely that high intakes of these sugars in highly processed foods would cause the same problem.
  • So Big Food, Inc started relying on artificial sweeteners in their highly processed foods. But guess what? Artificial SweetenersRecent studies have suggested that artificial sweeteners in highly processed foods are associated with obesity, diabetes, and heart disease.
  • That has caused Big Food, Inc to rely more on sugar alcohols in their highly processed foods, particularly erythritol because it is the least expensive of the sugar alcohols. Now the current study comes along and suggests that high intake of erythritol in highly processed foods may increase the risk of heart disease.
  • If this hypothesis is confirmed by better designed studies, it is not clear what Big Food, Inc will do next. The metabolomic study described above showed that high blood levels of several other sugar alcohols are associated with an increased risk of heart disease.

Hopefully, you are starting to see a pattern here. It’s time to ask the question, “Is it the sweetener, or is it the food?”

Clearly, it doesn’t matter what sweetener we are talking about. Large intake of any natural sweetener in the context of a diet rich in highly processed foods appears to have an adverse effect on our health. And we don’t know whether these adverse health effects are caused by the sweetener or some other component of the highly processed foods.

If you want to improve your health, the best solution is to decrease your intake of highly processed foods. That will automatically reduce your intake of sweeteners and other unhealthy components of highly processed foods and increase your intake of healthy components from the whole foods you will be eating instead.

Who Should Be Concerned About Erythritol Intake?

The authors of this study identified two groups who should be most concerned about erythritol consumption – diabetics and adherents of the keto diet.

  • Diabetics are at high risk because they are told to consume non-caloric sweeteners instead of sugars, and they are not told to avoid highly processed foods. Consequently, they consume much higher amounts of non-caloric sweeteners than the average American.
  • I must admit that I didn’t foresee keto adherents as a high-risk group. However, it appears that keto enthusiasts love their sweets as much as the rest of us, and the sweetener of choice for keto-friendly sweets is erythritol. The authors said that a single serving of keto ice cream contains 30 grams of erythritol. I can hardly imagine how much erythritol they must be getting in their diet.

And, once again, the best advice for both groups is to simply decrease the amount of highly processed food in their diet.

The Bottom Line 

Erythritol is not an artificial sweetener. It is found naturally in foods like grapes, peaches, pears, watermelons, and mushrooms. It is also found in some fermented foods like cheese, soy sauce, beer, sake, and wine.

It is also a byproduct of normal human metabolism, so we always have some of it circulating in our bloodstream. Our body knows how to handle erythritol.

That is why it was a surprise when a recent study claimed that high intake of erythritol is associated with an increased risk of heart attack and stroke. The Dr. Strangeloves of the world are already starting to tell you that erythritol is deadly and you should avoid it at all costs. But reputable scientists are saying, “Not so fast”.

This is the first study to suggest an association between erythritol and heart disease, and it was a highly flawed study.

In fact, the study showed that low to moderate intakes of erythritol had no effect on heart disease risk. It was only the highest intake of erythritol that was associated with increased risk of heart disease. And given the distribution of erythritol in the American diet, the only way someone could take in that much erythritol is to consume large amounts of erythritol-sweetened highly processed foods.

A brief review of the literature on sweeteners reveals that this is a common pattern for every natural sweetener tested. Low to moderate intake of these sweeteners has no adverse health effects. However, high intake of every sweetener tested in the context of a highly processed food diet is associated with an increased risk of obesity, diabetes, heart disease, and premature death.

That raises the question, “Is it the sweetener, or is it the food?”

Clearly, it doesn’t matter what sweetener we are talking about. Large intake of any natural sweetener in the context of a diet rich in highly processed foods is likely to have an adverse effect on our health. And we don’t know whether these adverse health effects are caused by the sweetener or some other component of a highly processed food diet.

If you want to improve your health, the best solution is to decrease your intake of highly processed foods. That will automatically reduce your intake of sweeteners and other unhealthy components of highly processed foods and increase your intake of healthy components from the whole foods you will be eating instead.

For more details on the study and information about which foods are likely to contain erythritol and the population groups who should be most concerned about erythritol consumption, 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

Which Supplements Are Good For Your Heart?

How Should You Interpret This Study? 

Author: Dr. Stephen Chaney 

strong heartFebruary 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?

Clinical StudyThis 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-3s And Heart DiseaseOmega-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?

Question MarkIn 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 acidFolic 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.

Do Calcium Supplements Increase Heart Attack Risk?

 

Calcium Confusion

Author: Dr. Stephen Chaney

 cardiovascular-disease

Should you avoid calcium supplements? Do calcium supplements increase heart disease risk? If you’ve been reading some of the recent headlines in magazines, newspapers and current health articles, that’s exactly what you might think.

And, after years of telling us that calcium supplements may be important for bone health, even some doctors are now recommending that their patients avoid calcium supplements. So what’s the truth? What should you believe?

Read more

Does An Apple A Day Keep Statins Away?

The Latest On Diet And Heart Health

Author: Dr. Stephen Chaney

AppleIn a previous “Health Tips From the Professor” I talked about how difficult it has been to prove that statins significantly reduce the risk of heart attack or cardiovascular deaths in a low risk population group. Now let’s look at the other side of the coin – lifestyle change –and ask how effective lifestyle change is at reducing the risk of cardiovascular disease.

You’ve all heard the saying “An apple a day keeps the doctor away”. It dates back to Victorian England. It was the public health message of the day – much simpler and more concise than our current food guide plate.

A prominent British doctor and his research team recently decided to see how accurate that saying really was. But they took their study one step further. They compared the effectiveness of an apple a day versus a statin a day at reducing the risk of cardiovascular deaths (Briggs et al, British Medical Journal, 3013;347:f7267 doi: 10.1136/bmj.f7267).

The results of that comparison may surprise you.

Does An Apple A Day Keep Statins Away?

They used the data from the Cholesterol Treatment Trialist meta-analysis to estimate the effectiveness of statin drugs at reducing cardiovascular deaths. They used the data from the PRIME comparative risk assessment model to estimate the effectiveness of apple a day at reducing cardiovascular deaths.

They asked what would happen if each of them were the primary intervention for the entire British population over 50 who were not currently taking statin drugs (17.6 million people).

They assumed a 70% compliance rate for both interventions. In simple terms that means they assumed that 70% of the population would actually do what their doctors told them. (Patients must be more compliant in England than in the US).

The results were interesting. They estimated that:

  • Giving a statin drug each day to 17.6 million people would reduce the number of cardiovascular deaths by 9,400.
  • Giving an apple each day to the same 17.6 million people would reduce the number of cardiovascular deaths by 8,500 (not significantly different).

But when they looked at side effects and cost the two interventions were significantly different.

  • Giving a statin drug each day to 17.6 million people would also cause some significant side effects. The authors estimated that it would lead to:
    • 1,200 excess cases of severe muscle pain and weakness
    • 200 excess cases of rhabdomyolysis (muscle breakdown, which can lead to irreversible kidney failure)
    • 12,300 excess cases of diabetes
  • On the other hand, there are no known side effects to an apple a day.
  • The statin intervention would cost an estimated $295 million. In the case of apples, you would presumably be substituting a more healthy food for a less healthy food so there would be little or no net cost.

And the 70% compliance rate is probably wildly optimistic. Some experts have estimated that up to 50% of patients discontinue their statin medications within the first year because of side effects or cost.

Is There A Scientific Basis For Those Estimates?

Of course, we all know that the “apple a day…” saying was never meant to be taken literally. It was just a simple way of saying that a good diet will reduce the risk of disease.

It turns out that there was another major study on the effect of dietary fiber on reducing the risk of cardiovascular disease in the very same issue (Threapleton et al, British Medical Journal, 2013;347:f6879 doi: 10.1136/bmj.f6879). It was a meta-analysis that combined the data from 22 previously published studies.

This study showed:

  • For every 7 g/day increase in dietary fiber the risk of both heart attacks and cardiovascular disease decreases by 9% (7 grams of dietary fiber could come from one serving of whole grains plus one serving of beans or lentils or from two servings of fruits or vegetables).
  • For every 4g/day of fruit fiber (equivalent to one apple) the risk of heart attacks decreases by 8% and the risk of cardiovascular disease decreases by 4%.
  • The numbers are similar for every 4 g/day of vegetable fiber.

Another recent study showed that consumption of 75 g/day of dried apple (equivalent to two apples a day) lowered total cholesterol by 13% and LDL-cholesterol by 24% in post-menopausal women (Chai et al, J. Acad Nutr Diet, 112: 1158-1168, 2012). That’s comparable to the cholesterol reduction achieved with statin drugs.

The Bottom Line

  • If you have not previously had a heart attack and are at relatively low risk, something as simple as adding an apple a day (in place of less healthy foods) may just as effective as statin drugs at reducing your risk of cardiovascular death without the side effects and cost of the drugs.
  • This is not really new information. For years both the American Heart Association and the National Institutes of Health have recommended that Therapeutic Lifestyle Changes (weight loss, healthy diet and exercise) should be tried BEFORE drug treatment to reduce the risk of heart disease.
  • So if you want to avoid statins, tell your doctor that you are willing to make the needed lifestyle changes to reduce your risk of heart disease and stick with it. Lifestyle changes are hard, but clinical studies clearly show they can often be just as effective as drug therapy, without the cost and side effects.
  • Don’t misunderstand me. I’m not advocating avoiding statin drugs if they are absolutely necessary. If you have had a heart attack or are at high risk of heart disease, it is clear that statins can save lives. Even here I would recommend talking with your physician about incorporating therapeutic lifestyle change into your regimen. It may allow them to minimize the dose, and therefore the side effects, of the statin drugs.

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.

Health Tips From The Professor