heart healthy

Which Diets Are Heart Healthy?

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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

Which Diets Are Heart Healthy?

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What Does A Heart Healthy Diet Look Like?

Author: Dr. Stephen Chaney 

heart attacksHeart disease is a big deal. According to the CDC, “Heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. One person dies every 33 seconds in the United States from cardiovascular disease. About 695,000 people in the United States died from heart disease in 2021 – that’s 1 in every 5 deaths”.

This doesn’t have to happen. According to the Cleveland Clinic, “90 percent of heart disease is preventable through healthier diet, regular exercise, and not smoking”. For this issue of “Health Tips From the Professor”, I will focus on the role of diet on heart health.

The problem is many Americans are confused. They don’t know what a heart-healthy diet is. There is so much conflicting information on the internet.

Fortunately, the American Heart Association has stepped in to clear up the confusion.

In 2021 they reviewed hundreds of clinical studies and published “Evidence-Based Dietary Guidance to Promote Cardiovascular Health”.

And recently they have published a comprehensive review (CD Gardner et al, Circulation, 147: 1715-1730, 2023) of how well popular diets align with their 2021 dietary guidelines.

I will cover both publications below. But first I want to address why Americans are so confused about which diets reduce heart disease risk.

Why Are Americans Confused About Diet And Heart Disease Risk?

I should start by addressing the “elephant in the room”.

  • As I discussed in last week’s “Health Tips From the Professor” article, Big Food Inc has seduced us. They have developed an unending supply of highly processed foods that are cheap, convenient, easy to prepare, and fulfill all our cravings. These foods are not heart-healthy, but they make up 73% of our food supply.

The Institute of Medicine, the scientific body that sets dietary standards, states that a wide range of macronutrient intakes are consistent with healthy diets. Specifically, they recommend carbohydrate intake at 45% to 65%, fat intake at 20% to 35%, and protein intake at 10% to 35% of total calories. (Of course, they are referring to healthy carbohydrates, fats, and proteins.)

The authors of this article pointed to several reasons why Americans have been misled about heart-healthy diets.

  • Many of the most popular diets fall outside of the “Acceptable Macronutrient Range”.
  • Many popular diets exclude heart-healthy food groups.

And, the words of the authors,

  • “Further contributing to consumer misunderstanding is the proliferation of diet books, [and] blogs [by] clinicians with limited understanding of what the dietary patterns entail and the evidence base for promoting cardiometabolic health.” I call these the Dr. Strangeloves of our world.

What Does A Heart Healthy Diet Look Like?

Let me start by sharing the American Heart Association’s 10 “Evidence-Based Dietary Guidelines to Promote Cardiovascular Health.

#1: Adjust energy intake and expenditure to achieve and maintain a healthy body weight
#2: Eat plenty of vegetables and fruits; choose a wide variety
#3: Choose foods made mostly with whole grains rather than refined grains
#4: Choose healthy sources of protein
Mostly from plants (beans, other legumes, and nuts)
Fish and seafood
Low-fat or fat-free dairy products instead of full-fat dairy products
If meat or poultry are desired, choose lean cuts and avoid processed forms
#5. Use liquid plant oils (olive, safflower, corn) rather than animal fats (butter and lard) and tropical oils (coconut and palm kernel)
#6. Use minimally processed foods instead of highly processed foods
#7: Minimize intake of beverages and foods with added sugars
#8: Choose and prepare foods with little or no salt
#9: If you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake
#10: Adhere to this guidance regardless of where food is prepared or consumed

Here are my comments on these guidelines:

  • If you have been reading my “Health Tips From the Professor” blog for a while, you probably realize that these aren’t just guidelines to promote heart health. These guidelines also reduce the risk of diabetes, cancer, inflammatory diseases, and much more.
  • If you have read my post on coconut oil, you will know that I have a minor disagreement with the AHA recommendation to avoid it. There is no long-term evidence that coconut oil is bad for the heart. But there is also no long-term evidence that it is good for the heart. My recommendation is to use it sparingly.
  • And you probably know there has been considerable discussion recently about whether full fat dairy is actually bad for the heart. In my most recent review of the topic, I concluded that if full fat dairy is heart healthy, it is only in the context of a primarily plant-based diet and may only be true for fermented dairy foods like unpasteurized yogurt and kefir.
  • Finally, guideline 10 may need some translation. Basically, this guideline is just asking how easy it is to follow the diet when you are away from home.

Which Diets Are Heart Healthy?

confusionIn evaluating how well diets adhered to the American Heart Association guidelines the authors ignored item 1 (energy intake) because most of the diets they evaluated did not provide any guidelines on how many calories should be consumed.

Each diet was given a score between 0 (Fail) and 1 (A+) for each of the other 9 guidelines by a panel of experts. The points for all 9 guidelines were added up, giving each diet a rating of 0 (worst) to 9 (best). Finally, a score of 9 was assigned 100%, so each diet could be given a percentage score for adherence to heart-healthy guidelines.

Here are the results:

Tier 1 diets (the most heart healthy diets) received scores of 86% to 100%. Going from highest (100%) to lowest (86%), these diets were:

  • DASH, Nordic, Mediterranean, Pescetarian (vegetarian diets that allow fish), and Ovo-Lacto Vegetarian (vegetarian diets that allow dairy, eggs, or both).
  • You will notice that these are all primarily plant-based diets.

Tier 2 diets were Vegan and other low-fat diets (TLC, Volumetrics). They both received scores of 78%.

  • The Vegan diet received 0 points for category 10 (ease of following the diet when eating out). It was also downgraded in category 7 for not having clear guidance for the use of salt when preparing foods.
  • The other low-fat diets were downgraded in categories 7, 10, and 5 (use of tropical oils).

Tier 3 diets received scores of 64% to 72%. They included very-low fat diets (<10% fat, very strict vegan diets) and low-carb diets (Zone, South Beach, Low-Glycemic Index).

  • They received 0 points for category 10 and were downgraded for eliminating heart-healthy food groups (liquid plant oils for the very low-fat diets, and fruits, vegetables, whole grains, and plant proteins for the low-carb diets).

Tier 4 diets (the least heart healthy diets) were the Paleo diet with a score of 53% and very low-carb diets (Atkins and Ketogenic) with a score of 31%.

  • The Paleo diet received 0 points for categories 10, 3 (choose whole grains), and 5 (using liquid plant oils rather than animal fats or tropical oils). It was also downgraded for lack of healthy plant-based protein sources.
  • The very low-carb diets were the least heart healthy. They received 0 points for categories 2 (eat plenty of fruits and vegetables), 3 (choose whole grains), 3 (healthy protein sources), 5 (use liquid plant oils instead of animal fats), 7 (minimize salt consumption), and 10 (ease of following the diet away from home).

The authors concluded, “Numerous [dietary] patterns [are] strongly aligned with 2021 American Heart Association Dietary Guidance (ie, Mediterranean, DASH, pescetarian, vegetarian) [and] can be adopted to reflect personal and cultural preferences and budgetary constraints.

Thus, optimal cardiovascular health would be best supported by developing a food environment that supports adherence to these patterns wherever food is prepared or consumed.”

Given our current food environment that last statement is wildly optimistic. But at least you have the information needed to make the best food choices for you and your family

The Bottom Line 

In 2021 the American Heart Association published 10 guidelines for evaluating heart-healthy diets. A recent study looked at how well popular diets adhered to those guidelines. The authors separated the diets into four categories (tiers) based on how heart-healthy they were. The results were not surprising:

  • Tier 1 diets (the most heart healthy diets) were DASH, Nordic, Mediterranean, Pescetarian (vegetarian diets that allow fish), and Ovo-Lacto Vegetarian (vegetarian diets that allow dairy, eggs, or both).
  • Tier 2 diets were Vegan and other low-fat diets (TLC, Volumetrics).
  • Tier 3 diets included very-low fat diets (<10% fat, very strict vegan diets) and low-carb diets (Zone, South Beach, Low-Glycemic Index).
  • Tier 4 diets (the least heart healthy diets) were the Paleo diet and very low-carb diets (Atkins and Ketogenic).

The authors concluded, “Numerous [dietary] patterns [are] strongly aligned with 2021 American Heart Association Dietary Guidance (ie, Mediterranean, DASH, pescetarian, vegetarian) [and] can be adopted to reflect personal and cultural preferences and budgetary constraints.

Thus, optimal cardiovascular health would be best supported by developing a food environment that supports adherence to these patterns wherever food is prepared or consumed.”

Given our current food environment that last statement is wildly optimistic. But at least you have the information needed to make the best food choices for you and your family.

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

Which Diets Are Best In 2023?

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Which Diet Should You Choose?

Author: Dr. Stephen Chaney

Emoticon-BadMany of you started 2023 with goals of losing weight and/or improving your health. In many cases, that involved choosing a new diet. That was only 6 weeks ago, but it probably feels like an eternity.

For many of you the “bloom” has gone off the new diet you started so enthusiastically in January.

  • Perhaps the diet isn’t working as well as advertised…
  • Perhaps the diet is too restrictive. You are finding it hard to stick with…
  • Perhaps you are always hungry or constantly fighting food cravings…
  • Perhaps you are starting to wonder whether there is a better diet than the one you chose in January…
  • Perhaps you are wondering whether the diet you chose is the wrong one for you…

If you are rethinking your diet, you might want to know which diets the experts recommend. Unfortunately, that’s not as easy as it sounds. The diet world has become just as divided as the political world.

Fortunately, you have an impartial resource. Each year US News & World Report invites a panel of experts with different points of view to evaluate popular diets. They then combine the input from all the experts into rankings of the diets in various categories.

If you are still searching for your ideal diet, I will summarize the US News & World Report’s “Best Diets In 2023”. For the full report, click on this link.

How Was This Report Created?

Expert PanelUS News & World Report recruited a panel of 30 nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes, and heart disease to review the 24 most popular diets.

The diets evaluated are not the same each year. Last year they evaluated the top 40 most popular diets. This year they only reviewed the top 24.

That means some good diets were left off the list. For example, the vegan diet is very healthy, but it is also very restrictive. Very few people follow a pure vegan diet, so it didn’t make the top 24 most popular. However, this year’s list did include several primarily plant-based diets that are more popular with the general public.

The panel is also not the same each year. Some experts are rotated off the panel, and others are added. The experts rate each diet in seven categories:

  • How easy it is to follow.
  • Its ability to produce short-term weight loss.
  • Its ability to produce long-term weight loss.
  • its nutritional completeness.
  • Its safety.
  • Its potential for preventing and managing diabetes.
  • Its potential for preventing and managing heart disease.

They converted the experts’ ratings to scores 5 (highest) to 1 (lowest). They then used these scores to construct eleven sets of Best Diets rankings:

  • Best Diets Overall ranks diets on several different parameters, including whether all food groups are included in the diet, the availability of the foods needed to be on the diet and the use of additional vitamins or supplements. They considered if the diet was evidence-based and adaptable to meet cultural, religious, or other personal preferences. In addition, the criteria also included evaluation of the prep and planning time required for the diet and the effectiveness of the diet for someone who wants to get and stay healthy.
  • Best Plant-Based Diets used the same approach as Best Diets Overall to rank the eight plans emphasizing minimally processed foods from plants that were included in this year’s ratings.
  • Best Commercial Diet ratings used the same approach to rank 15 commercial diet programs that require a participation fee or promote the use of branded food or nutritional products.
  • Best Long-Term Weight-Loss Diet ratings were generated by combining the safety of the rate of weight loss promoted and the likelihood of the plan to result in successful long-term weight loss and maintenance of weight loss.
  • Best Fast Weight-Loss Diets were scored on their effectiveness for someone who wants to lose weight in three months or less.
  • Best Diabetes Diet ratings were calculated equally from the effectiveness of the diet for someone who wants to lower risk factors for diabetes, the nutritional quality of the diet, and research evidence-based support for the diet.
  • Best Heart-Healthy Diet ratings were calculated equally from the effectiveness of the diet for someone who wants to lower risk factors for hypertension and other forms of heart disease, the nutritional quality of the diet, and evidence-based support for the diet.
  • Best Diets for Bone and Joint Health were calculated equally on the effectiveness of the diet for someone who wants to lower their risk factors for inflammation and improve bone and joint health, as well as the nutritional quality and research evidence-based support for the diet.
  • Best Diets for Healthy Eating combines nutritional completeness and safety ratings, giving twice the weight to safety. A healthy diet should provide sufficient calories and not fall seriously short on important nutrients or entire food groups.
  • Easiest Diets to Follow represents panelists’ averaged scores for the relevant lifestyle questions, including whether all food groups are included and if the recommended foods are readily available at the average supermarket.
  • Best Family-Friendly Diets were calculated equally on their adaptability for the whole family, including cultural, religious, and personal preferences, the time required to plan and prep, nutritional value and access to food at any supermarket.

Which Diets Are Best In 2023?

Are you ready? If this were an awards program, I would be saying “Envelop please” and would open the envelop slowly to build suspense.

However, I am not going to do that. Here are the top 3 and bottom 3 diets in each category (If you would like to see where your favorite diet ranked, click on this link.

[Note: I excluded commercial diets from this review. (I have a brief discussion of commercial diets below). If you notice a number missing in my summaries, it is because I eliminated one or more commercial diet from my summary.]

Best Diets Overall 

The Top 3: 

#1: Mediterranean Diet. The Mediterranean diet has been ranked #1 for 6 consecutive years.

#2 (tie): DASH Diet (This diet was designed to keep blood pressure under control, but you can also think of it as an Americanized version of the Mediterranean diet.)

#2 (tie): Flexitarian Diet (A flexible semi-vegetarian diet).

The Bottom 3: 

#20: Keto Diet (A high protein, high fat, very low carb diet designed to achieve ketosis).

#21: Atkins Diet (The granddaddy of the high animal protein, low carb, high fat diets).

#24: Raw Food Diet (A diet based on eating foods that have not been cooked or processed).

Best Plant-Based Diets Overall 

The Top 3: 

#1: Mediterranean Diet.

#2: Flexitarian Diet.

#3: MIND Diet (This diet is a combination of Mediterranean and DASH but is specifically designed to reduce cognitive decline as we age.)

The Bottom 3: 

Since only 8 diets were included in this category, even the bottom 3 are pretty good diets, so I did not include a “list of shame” in this category.

Best Long-Term Weight-Loss DietsWeight Loss

The Top 3: 

#1: DASH Diet

#2 (tie): Volumetrics Diet (A diet based on the caloric density of foods).

#2 (tie): Mayo Clinic Diet (A diet designed to establish lifelong healthy eating habits).

The Bottom 3: 

#22 (tie): Keto Diet.

#22 (tie): Atkins Diet.

#24: Raw Food Diet.

Best Fast Weight-Loss Diets

The Top 3: 

#1: Keto Diet

#2: Atkins Diet

#7 (tie): Mayo Clinic Diet

#7 (tie): South Beach Diet

#7 (tie): Volumetrics Diet

The Bottom 3: 

The diets at the bottom of this list were designed for health and weight maintenance rather than rapid weight loss, so I did not include a “list of shame” in this category.

Best Diabetes Diets

The Top 3: 

#1: DASH Diet

#2: Mediterranean Diet

#3: Flexitarian Diet

The Bottom 3: 

#20: Atkins Diet

#21: Paleo Diet (A diet based on what our paleolithic ancestors presumably ate. It restricts grains and dairy and is heavily meat-based).

#22: Raw Food Diet.

Best Heart-Healthy Diets

Healthy HeartThe Top 3: 

#1: DASH Diet

#2: Mediterranean Diet

#3 (tie): Ornish Diet (A whole food, semi-vegetarian diet designed to promote heart health).

#3 (tie): Flexitarian Diet

The Bottom 3: 

#22 (tie): Raw Foods Diet

#22 (tie): Paleo Diet

#24: Keto Diet

Best Diets for Bone and Joint Health 

The Top 3: 

#1 (tie): DASH Diet

#1 (tie): Mediterranean Diet

#3: Flexitarian Diet

The Bottom 3: 

#21 (tie): Raw Foods Diet

#21 (tie): Paleo Diet

#22: Atkins Diet 

#23: Keto Diet 

Best Diets for Healthy Eating

The Top 3: 

#1: Mediterranean Diet

#2: DASH Diet

#3: Flexitarian Diet

The Bottom 3: 

#22: Keto Diet

#23: Atkins Diet

#24: Raw Foods Diet

Easiest Diets to FollowEasy

The Top 3: 

#1 (tie): Flexitarian Diet

#1 (tie): TLC Diet (This diet was designed by the NIH to reduce cholesterol levels and promote heart health.)

#3 (tie): Mediterranean Diet

#3 (tie): DASH Diet

The Bottom 3: 

#19: Atkins Diet

#20: Keto Diet

#22: Raw Foods Diet

Which Diets Are Best For Rapid Weight Loss?

Happy woman on scaleThere are 2 take-home lessons from the rapid weight loss category:

  1. If you are looking for rapid weight loss, any whole food restrictive diet will do.
    • Last year’s diet analysis included the vegan diet, and both vegan and keto diets ranked near the top of the rapid weight loss category. Keto and vegan diets are both very restrictive, but they are polar opposites in terms of the foods they allow and restrict.
      • The keto diet is a meat heavy, very low carb diet. It restricts fruits, some vegetables, grains, and most legumes.
      • The vegan diet is a very low-fat diet that eliminates meat, dairy, eggs, and animal fats.
    • The Atkins and keto diets toppled this year’s rapid weight loss list, but they were joined by the Mayo Clinic, South Beach, and volumetrics diets. Those diets are also restrictive, but, like the vegan diet, they are very different from the Atkins and keto diets.
    • I did not include commercial diets that rated high on this list, but they are all restrictive in one way or another.

2) Whole food, very low carb diets like Atkins and keto are good for rapid weight loss, but they rank near the bottom of the list for every healthy diet category.

    • If you choose to lose weight on the Atkins or keto diets, switch to a healthier diet once you reach your desired weight loss.

Which Diet Should You Choose?

Food ChoicesWith rapid weight loss out of the way, let’s get back to the question, “Which Diet Should You Choose?” My recommendations are:

1) Choose a diet that fits your needs. That is one of the things I like best about the US News & World Report ratings. The diets are categorized. If your main concern is diabetes, choose one of the top diets in that category. If your main concern is heart health… You get the point.

2) Choose diets that are healthy and associated with long term weight loss. If that is your goal, you will notice that primarily plant-based diets top these lists. Meat-based, low carb diets like Atkins and keto are near the bottom of the lists.

  • “Why is that?”, you might ask? The answer is simple. And it’s not that all 30 experts were prejudiced against low carb diets. It’s that the major primarily plant-based diets like Mediterranean, DASH, and flexitarian are backed by long-term clinical studies showing they are healthy and significantly reduce the risk of diabetes, heart disease, and other chronic diseases.
  • On the other hand, there are no long-term studies showing the Atkins and keto diets are healthy long term. And since the Atkins diet has been around for more than 50 years, the lack of clinical evidence that it is healthy long term is damming.

3) Choose diets that are easy to follow. The less-restrictive primarily plant-based diets top this list – diets like Mediterranean, DASH, MIND, and flexitarian. They are also at or near the top of almost every diet category.

4) Choose diets that fit your lifestyle and dietary preferences. For example, if you don’t like fish and olive oil, you will probably do much better with the DASH or flexitarian diet than with the Mediterranean diet.

5) Finally, focus on what you have to gain, rather than on foods you have to give up.

  • On the minus side, none of the diets include sodas, junk foods, and highly processed foods. These foods should go on your “No-No” list. Sweets should be occasional treats and only as part of a healthy meal. Meat, especially red meat, should become a garnish rather than a main course.
  • On the plus side, primarily plant-based diets offer a cornucopia of delicious plant foods you probably didn’t even know existed. Plus, for any of the top-rated plant-based diets, there are websites and books full of mouth-watering recipes. Be adventurous.

What About Commercial Diets?

I chose not to review commercial diets by name, but let me make a few observations.

  • If you look at the gaps in my lists, it should be apparent that several commercial diets rank near the top for fast weight loss, but near the bottom on most healthy diet lists.
  • I do not recommend commercial diets that rely on ready-to-eat, low-calorie, highly processed versions “of your favorite foods”.
    • These pre-packaged meals are expensive. Unless you are a millionaire, you won’t be able to afford these meals for the rest of your life.
    • These pre-packaged meals are not teaching you healthy eating habits that will allow you to keep the weight off.
  • If you wish to spend your hard-earned dollars on a commercial diet, choose a diet that:
    • Relies on whole foods from all 5 food groups.
    • Teaches and provides support for the type of lifestyle change that leads to permanent weight loss.
  • Meal replacement shakes can play a role in healthy weight loss if:
    • They are high quality and use natural ingredients as much as possible.
    • They are part of a holistic lifestyle change program.

The Bottom Line 

For many of you the “bloom” has gone off the new diet you started so enthusiastically in January. If you are rethinking your diet, you might want to know which diets the experts recommend. Unfortunately, that’s not as easy as it sounds. The diet world has become just as divided as the political world.

Fortunately, you have an impartial resource. Each year US News & World Report invites a panel of experts with different points of view to evaluate popular diets. They then combine the input from all the experts into rankings of the diets in various categories. In the article above I summarize the US News & World Report’s “Best Diets In 2023”.

There are probably two questions at the top of your list.

#1: Which diets are best for rapid weight loss? Here are 2 general principles:

  1. If you are looking for rapid weight loss, any whole food restrictive diet will do.

2) If you choose to lose weight on the Atkins or keto diets, switch to a healthier diet once you reach your desired weight loss. Atkins and keto diets are good for rapid weight loss, but they rank near the bottom of the list for every healthy diet category.

#2: Which diet should you choose? Here the principles are:

  1. Choose a diet that fits your needs.

2) Choose diets that are healthy and associated with long term weight loss.

3) Choose diets that are easy to follow.

4) Choose diets that fit your lifestyle and dietary preferences.

5) Finally, focus on what you have to gain, rather than on foods you have to give up.

For more details on the diet that is best for you and my thoughts on commercial diets, read the article above.

What Is The Truth About Low Carb Diets?

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Why Is The Cochrane Collaboration The Gold Standard?

Author: Dr. Stephen Chaney 

low carb dietAtkins, 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?

ghost bustersWho 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?

Clinical StudyThe 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?

The TruthAll 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?

confusionIf 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.

Eating Of The Green

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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?

health benefits of beetroot juiceWe 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?

Clinical StudyThis 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?

strong heartIntake 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?

questionsYou 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

spinachYour 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.

Is Margarine Healthier Than Butter?

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What Should You Put On Your Toast?

Author: Dr. Stephen Chaney

The Checkered History Of Margarine

MargarineMany of you may have seen the recent headlines proclaiming that a recent study has shown that margarine is healthier than butter.

  • Some of you may be saying, “I don’t believe it.”
  • Others may be saying, “Of course. Hasn’t that always been true.”

So, to clear up the confusion, let me share a brief history of margarine.

  • Margarine was invented in 1869 by a French chemist in response to a request from Napoleon III to create a poor man’s butter substitute. Napoleon’s intentions weren’t entirely altruistic. He also wanted a cheaper butter substitute for his armies.
  • Margarine initially encountered a strong headwind in this country. The dairy lobby influenced congress and state legislatures to pass numerous laws designed to increase the cost and reduce the desirability of margarine.
  • In the 1950s the ground started to shift. Scientists and the medical community started to recognize that saturated fats were a major contributor to heart disease. Suddenly, butter became a villain, something to avoid.
    • But that was a problem. Butter was preferred spread for bread and toast. It was used for cooking. It was ubiquitous. You may even remember the popular “I like bread and butter” song. What was a person to do?
  • At that time margarine was made by partially hydrogenating vegetable oils (usually corn oil because it was the cheapest). The hydrogenation converted some of the unsaturated fats in vegetable oils to saturated fats so that margarine would not be in liquid form at room temperature. However, the total amount of saturated fat in margarine was less than in butter, and the ratio of polyunsaturated fat to saturated fats was much healthier. Margarine took on a new luster. It was now the healthier alternative to butter.
    • Once margarine attained the “healthier” status, most of the anti-margarine laws were quickly abolished, and margarine quickly outpaced butter as the spread of choice.
  • In the 1980s the ground shifted again. A French study found the margarine increased the risk of heart disease more than butter. Further studies showed that the hydrogenation process created a novel type of fat called trans fats. By the 1990s it was widely accepted that trans fats increased the risk of heart disease even more than saturated fats.
    • Margarine became the villain, and butter was considered the more natural, healthier spread. By 2000 sales of butter once more surpassed those of margarine.
  • In 2018 the ground shifted once again. After almost 20 years of deliberation, the FDA banned trans fats from the American food supply as of 2018. Margarine no longer contained trans fats.

Today’s study (C Weber et al, Public Health Nutrition, doi:10.1017/S1368980021004511) asks whether the reformulated, trans-fat-free margarines are once again a healthier alternative to butter.

Is Margarine Healthier Than Butter? 

Margarine-Versus-ButterThe study analyzed the fat composition of 53 margarine tub or squeeze products, 18 margarine stick products, 12 margarine-butter blend products and compared them with the fat composition of butter. The results are shown below:

There was no detectable trans fat in any of the margarine products. So, based on saturated fat content and the ratio of unsaturated fats to saturated fats, the margarine products were all healthier than butter. This is what the paper concluded.

Mean % of Total Fat In:
Margarine

Tub or Tube

 Margarine

Sticks

 Margarine-

Butter Blends

 Butter
SFA* 29% 38% 38% 60%
MUFA* 36% 34% 43% 26%
PUFA* 33% 29% 13% 4%
*SFA = Saturated fats, MUFA = Monounsaturated fats,

PUFA = Polyunsaturated fats

But let’s look a bit deeper. First, we should look at the fat sources.

  • The saturated fat in the margarine products comes from either palm or coconut oil. There are claims that these plant saturated fats may be healthier than saturated fats from animal sources. But there are no long-term studies to back up those claims, So, I will simply consider them equivalent to any other saturated fat for this review.

Next, we should look at the labels.

  • The labels of most butter products are simple. Butter is sweet cream and salt. Unsalted butter is sweet cream and natural flavoring (usually lactic acid). This is the way that butter has been made for hundreds of years.
  • Margarine products are manufactured foods. They didn’t come from a cow. Their labels are significantly longer. And you should read the labels carefully.
    • Some margarine products are made with natural ingredients.
    • However, many margarine products contain preservatives and artificial flavors.

So, choosing between margarine products and butter is not as simple as looking at saturated fat content alone.

But what if you didn’t have to choose between margarine and butter? What if there were other options to consider?

What Should You Put On Your Toast?

Peanut Butter and Jelly Sandwich on Whole WheatOnce you decide to look beyond margarine and butter you will find lots of healthy options. For example:

  • If you have ever eaten at a fine Italian or Greek restaurant, you may have had your bread served with olive oil to dip it in. Of course, this may be a better option for lunch and dinner than for breakfast. (I don’t think jam would pair well with olive oil.)
  • Nut butters are an excellent choice any time of day. Peanut and almond butters are the most popular, but there are many other nut butters to choose from.
  • Avocado is another excellent choice.
  • This just scratches the surface. There are healthier options for almost every palate.

If you look at the fat composition of my top four suggestions, you can readily see why they are healthier choices than either margarine or butter. They are much lower in saturated fat and high in heart healthy monounsaturated and polyunsaturated fats.

Mean % of Total Fat In:
Olive

Oil

 Almond

Butter

 Peanut

Butter

 Avocado
SFA* 14% 9% 22% 16%
MUFA* 74% 64% 53% 71%
PUFA* 12% 27% 25% 13%
*SFA = Saturated fats, MUFA = Monounsaturated fats,

PUFA = Polyunsaturated fats

 

But that is just part of the story:

  • Nut butters are also a good source of protein. And both nut butters and avocados provide nutrients, phytonutrients, and fiber you don’t find in margarine or butter.

There are also labels to consider:

  • Avocados are whole foods and don’t require labels. There are no other ingredients. What you see is what you get.
  • Olive oil is a bit more complicated. It is often blended with cheaper oils to reduce the cost, and that doesn’t always show up on the label. My best advice is to get extra virgin olive oil from a brand you trust.
  • With nut butters, you should read the label. For example, the ingredient label for almond butter should list almonds as the sole ingredient. Peanut butter should just list peanuts. However, some brands add other oils, sugar, emulsifying agents, etc. These are the brands you should leave on the shelf.

Our “go-to” spread is almond butter. I like it with cinnamon sprinkled on top, although sliced bananas and cinnamon is another excellent choice.

As for butter, we still like it on baked sweet potatoes and corn on the cob. We freeze our butter and cut off a slice whenever we need it. A stick of butter lasts us many months.

The Bottom Line

Now that trans fats have been removed from margarine products a recent study revisited the question as to whether margarine or butter was the healthier choice. On the basis of their saturated fat content, the study concluded that margarine products were healthier than butter.

However, that is just part of the story. When you look at the labels:

  • The labels of most butter products are simple. Butter is sweet cream and salt. Unsalted butter is sweet cream and natural flavoring (usually lactic acid). This is the way that butter has been made for hundreds of years.
  • Margarine products are manufactured foods. They didn’t come from a cow. Their labels are significantly longer. And you should read the labels carefully.

So, choosing between margarine products and butter is not as simple as looking at saturated fat content alone. But what if you didn’t have to choose between margarine and butter? What if there were other options to consider?

Once you decide to look beyond margarine and butter you will find lots of healthy options. I discuss my top 4 choices above.

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?

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Is Dairy Right For You? 

Author: Dr. Stephen Chaney

dairy foodsWe 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?

dairy products and heart disease cheeseBefore 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 Healthy Heart29 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.

balance scaleThe 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?

dairy products and heart disease questionsNow 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

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.

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.

Health Tips From The Professor