Category Archives: nutrition

Can goose liver, grass-fed meat, aged hard cheese, free range eggs and cod liver oil prevent a heart attack?

The data suggests that the answer is yes. The first four of these health foods are rich sources of vitamin K2 and the last food item is packed with Vitamins A and D. The proposed mechanism for their protective effect rests in a wonderful biological quartet. The instruments of this quartet include the fat soluble vitamins D, K2, and A playing harmoniously with a ubiquitous human protein called Matrix gla protein (MGP).

The basic science is exquisite. Vitamins D and A acting together enhance the expression of MGP. In other words, these two fat-soluble vitamins cause our bodies to increase the production of MGP. MGP resides throughout our bodies including the walls of our arteries. Vitamin K2 then activates the MGP which in turn regulates (prevents) the calcification of plaque in the walls of our arteries. MGP masterfully plays this role in many arteries and it’s artistry is particularly effective in the coronary arteries that supply blood and oxygen to heart muscle.

Heavily calcified coronary plaque (the nasty stuff that produces atherosclerosis) as compared to un-calcified plaque is much more likely to rupture and create an acute blockage, thereby causing a heart attack. By inhibiting calcification of coronary plaque activated MGP decreases the risk of a heart attack. The biochemistry and physiology of this process are well accepted and discussed in the opening of several papers that address this topic. (1,2,3)

The data that support this theory includes a lot of basic science that describes the interaction between the four players as well as nutritional studies in humans and rodents.

The first major human study was the Rotterdam study published in the Journal of the American Society for Nutritional Sciences, 2004. Here is a quote from the summary.

“Vitamin K-dependent proteins, including matrix Gla-protein, have been shown to inhibit vascular calcification. Activation of these proteins via carboxylation depends on the availability of vitamin K. We examined whether dietary intake of phylloquinone (vitamin K-1) and menaquinone (vitamin K-2) were related to aortic calcification and coronary heart disease (CHD) in the population-based Rotterdam Study.”

The study followed 4801 adults for over 7 years and analyzed the relationship between Vitamin K intake and incidence of heart attacks, (fatal and non-fatal), death from all causes, and atherosclerosis in the aorta (the major artery of the body). The results were impressive. The analysis divided the 4801 people into three equal groups, 1/3 with the highest consumption of Vitamin K, 1/3 with the lowest consumption, and 1/3 in the middle. The higher and middle groups compared to the group with the lowest consumption had:

significantly fewer non-fatal heart attacks,
significantly fewer deaths from heart attack,
significantly fewer deaths from all causes.

In addition, the group with the highest consumption of Vitamin K2 had significantly less calcified plaque in the walls of their aortas.

Comparing the group of the highest intake of vitamin K2 to the group with the lowest intake, the highest intake group had 41% less risk of non-fatal heart attack, 57% lower risk of death from heart attack and 26% lower risk of death from all causes after adjusting for multiple factors that are believed to play a role in heart attack risk. (Those other factors included age, gender, total energy intake, BMI, smoking status, pack-years smoking, diabetes, education, alcohol consumption. consumption of saturated fat, poly unsaturated fat, flavonoids (anti-oxidants) and calcium.)

Vitamin K2 consumption showed these significant associations whereas Vitamin K1 did not. Vitamin K2 is found most abundantly in animal foods that contain erroneously demonized saturated fat, Vitamin K1 is found in plants that do not contain much if any saturated fat. So this represents not only a strong statistical signal for the health benefit of Vitamin K2, but also supports the health benefit of consuming animal foods with saturated fat. The individuals who consumed more meat and more full fat fermented cheese (the two major sources of vitamin K2 in this study) had dramatically reduced risk of heart attack (both fatal and non-fatal), reduced risk of death from all causes, and less calcified plaque in the major artery of the body, the aorta. Vitamin K2 is a fat soluble vitamin which means it comes with the fat in these foods. Eating low fat foods misses this healthy opportunity.

Five years after the Rotterdam study was published, another study demonstrated similar findings. The title tells the story.

“A high menaquinone (vitamin K2) intake reduces the incidence of coronary heart disease.”

This study followed 16,057 women aged 49-70 years for 8 years. The study participants had no known heart disease at the start of the study. The results:

“After adjustment for traditional risk factors and (other) dietary factors, we observed an inverse association between vitamin K(2) and risk of CHD with a Hazard Ratio (HR) of 0.91 [95% CI 0.85-1.00] per 10 microg/d vitamin K(2) intake.”

Translation: for every increase in daily consumption of vitamin K2 by 10 micrograms per day, there was an average 9% reduction in risk of coronary disease events.

Let’s look at how much Vitamin K2 was consumed in the three groups described in the first study. Going from the lowest to the highest daily consumption the groups averaged 15.1, 26.9 and 40.9 micrograms per day. To put this in perspective, you can view a table of the Vitamin K2 content of various foods produced by Chris Masterjohn, a portion of which appears below. Before you do that, let me explain some facts about Vitamin K2.

Vitamin K2 actually represents a group of very similar vitamins that differ chemically only in the number of specific chemical side chains. The number of these side chains varies from 4 to 10, so these are referred to as MK-4 through MK-10. From Wikepedia:

All K vitamins are similar in structure: they share a “quinone” ring, but differ in the length and degree of saturation of the carbon tail and the number of “side chains”.^[1] The number of side chains is indicated in the name of the particular menaquinone (e.g., MK-4 means that four molecular units – called isoprene units – are attached to the carbon tail) and this influences the transport to different target tissues.

MK-4 is made in the tissue of grass-eating mammals that convert Vitamin K1 (from the green plants) to Vitamin K2 (MK-4). This can be obtained from animal muscle, organ meats, or the milk and milk products of mammals, including human breast milk.

The other forms of Vitamin K-2 (side-chain length > 4) are made by bacteria during the fermentation of foods (such as cheese, sauerkraut, kim chee and Natto). Here is the table from Chris Masterjohn. Go here for the original table.

The percentage of vitamin K₂ present as MK-4 represents that synthesized by animal tissues, while the remainder represents that synthesized by bacteria during fermentation.

FOOD	VITAMIN K2 (MCG/100G)
Natto	1103.4	(0% MK-4)
Goose Liver Paste	369.0	(100% MK-4)
Hard Cheeses	76.3	(6% MK-4)
Soft Cheeses	56.5	(6.5% MK-4)
Egg Yolk (Netherlands)	32.1	(98% MK-4)
Goose Leg	31.0	(100% MK-4)
Curd Cheeses	24.8	(1.6% MK-4)
Egg Yolk (United States)	15.5	(100% MK-4)
Butter	15.0	(100% MK-4)
Chicken Liver	14.1	(100% MK-4)
Salami	9.0	(100% MK-4)
Chicken Breast	8.9	(100% MK-4)
Chicken Leg	8.5	(100% MK-4)
Ground Beef (Medium Fat)	8.1	(100% MK-4)
Bacon	5.6	(100% MK-4)
Calf Liver	5.0	(100% MK-4)
Sauerkraut	4.8	(8% MK-4)
Whole Milk	1.0	(100% MK-4)

Where did our paleolithic hunter-gatherer ancestors get their Vitamin K2? They did not consume dairy products. Vitamin K2 is heavily concentrated in the pancreas, brain and liver of humans and animals. Hunter-gatherers do not waste these valuable fatty organs, in fact offal was deemed the most treasured part of a successful hunt among many hunter-gatherer societies studied during the 19th and 20th centuries.

Not many Americans eat offal such as pancreas, brain and liver so similar to Holland (where these studies were conducted) most Vitamin K2 in the American diet probably comes from hard cheese and egg yolks.

But what is the weakness in drawing conclusions from these two studies?

First they were epidemiological studies, the data was obtained from FFQs (food frequency questionnaires). They were not randomized controlled clinical trials (RCTs). There have been no RCTs that have looked specifically at Vitamin K2 relative to coronary artery disease and deaths. Having said that, you should be aware that most nutrition studies that have been published (in particular those that demonize saturated fat ) fall into the same category, they are epidemiological studies based upon food frequency questionnaires (FFQs) and such studies have been criticized with regards to reliability of data and for lack of controlling the multiple dietary and non-dietary factors that can influence health outcomes.(4)

Unlike the two studies discussed here that statistically adjusted for multiple known or argued risk factors, the epidemiologic studies that are alleged to suggest potential harm from saturated fat did not control or adjust for other statistical “con-founders”. In addition, the review papers that have so overwhelmed our society causing fat-phobia have ignored the large body of evidence that demonstrates the health benefits of consuming animal foods that contain fat soluble vitamins as well as many other vital nutrients. (4)

Regarding randomized controlled trials, there have been many convincing RCTs in rodents that demonstrate not only prevention of calcified plaques in arterial walls but actual reversal of atherosclerosis in rodents with high doses of vitamin K2. (5) Furthermore, a certain breed of experimental rodent that completely lacks MGP suffers from early death caused by severe atherosclerosis further supporting the fundamental role of activated MGP in maintaining vascular health. (6)

1. Dietary Intake of Menaquinone Is Associated with a Reduced Risk of Coronary Heart Disease: The Rotterdam Study

2. A high menaquinone intake reduces … [Nutr Metab Cardiovasc Dis. 2009] – PubMed – NCBI

3. Vitamin K status and vascular calcification: eviden… [Adv Nutr. 2012] – PubMed – NCBI

4. Dietary Fats and Health: Dietary Recommendations in the Context of Scientific Evidence

5. Regression of warfarin-induced medial elastocalcinosis… [Blood. 2007] – PubMed – NCBI

6. Two sides of MGP null arterial disease: chondrogenic lesions dependent on transglutaminase 2 and elastin fragmentation associated with induction of adipsin.

The Ornish Low Fat Vegetarian Diet, does it work?

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Dr. Dean Ornish has done wonderful research in the area of cardiovascular disease and lifestyle intervention. His study on comprehensive lifestyle intervention (1) is often quoted to support a low fat vegetarian diet as treatment for cardiovascular disease. But his “Intensive lifestyle changes for reversal of coronary heart disease” included several components that would be expected to improve health and decrease cardiovascular risk independent of a vegetarian diet as will be discussed below.

Let’s review what this study did.

48 patients with diagnosed moderate to severe coronary artery disease were randomized to one of two treatment groups, an “intensive lifestyle change” (ILC) group or a “usual-care” (UC) control group. 28 patients were allocated randomly to the ILC group and 20 were allocated to the UC group. Out of 48 patients starting the study only 35 completed the study, 20 out of 28 in the ILC group completed the study and 15 out of 20 in the UC group completed the study.

The intensive lifestyle change group followed this program:

10% fat whole foods vegetarian diet
daily aerobic exercise
stress management training (training in and daily performance of meditation and/or yoga)
smoke cessation (they quit smoking)
group psychosocial support (3 hour group therapy sessions)

At the start of the study only one patient in the ILC group was smoking and she quit. We do not know how many smokers were in the UC group or how many quit. (I consider that a deficiency of this study. Because smoking is such a significant determinant of cardiovascular outcome, details of smoking at start and end of the study for both groups should have been reported)

At the end of five years the intensive lifestyle change group demonstrated an average 3.1% absolute reduction in the coronary artery blockage as measured by coronary arteriograms (or to put it another way, the diameter of the blocked coronary arteries increased by 3.1%). The usual care group (receiving cholesterol lowering statin drugs) showed an average 2.3% absolute increase in the coronary artery blockage (2.3% reduction in diameter). These are not huge changes or differences but they were measurable and statistically significant.

Twenty five total “cardiac events” occurred in the 28 patients randomized to the intensive lifestyle change group over the five years and 45 cardiac events occurred in the 20 patients randomized to the “usual care” group (receiving cholesterol lowering statin drugs). But this was due to differences in the number of hospitalizations and angioplasties. There was no statistically significant difference in the number of deaths, heart attacks or coronary artery bypass surgeries.

By the end of the study 2 patients in the ILC group had died compared to 1 death in the usual care group but as mentioned above, this difference was not statistically significant. We do not know how many deaths occurred in the 8 patients who dropped out of the treatment group or in the 5 patients who dropped out of the usual care group, nor do we know any of the other outcomes for the drop-out patients.

So there were no lives saved by the intensive lifestyle change program and no reduction in the number of heart attacks. In fact the ILC group had 2 deaths compared to 1 in the usual care group.

What does this all mean and why has the Ornish Diet attracted so much attention.?

First, I would suggest that the demonstrated benefits (reductions in the number of angioplasties and hospitalizations) are likely explained by the following parts of the lifestyle changes.

stress reduction training and implementation (meditation and yoga)
elimination of manufactured trans-fats from the diet
elimination of unhealthy pro-inflammatory excess omega six fats (vegetable oils) from the diet
elimination/reduction of processed carbohydrates and sugar.

Although the intensive lifestyle intervention included regular exercise the data show no significant difference in times per week or hours per week of exercise at the end of the study between the two groups.

The big difference was in stress management. The ILC group averaged practicing meditation and/or yoga 5 times per week (48 minutes per day) versus less that once per week (8 minutes per day) in the usual care group.

Stress reduction is a major issue in any disease and in particular in cardiovascular disease.

Several studies have demonstrated that the daily practice of meditation improves immune function, increases telomerase activity, reduces inflammatory markers, and reduces circulating stress hormones (cortisol and epinephrine) independent of dietary changes.
Meditation has also been observed to improve “endothelial function”, the ability of the cells that line arteries to respond to changes in demand. (2,3,4,5,6,7)

Here is a press release from the American Heart Association 13 November 2012. (8)

“African Americans with heart disease who practiced Transcendental Meditation regularly were 48 percent less likely to have a heart attack, stroke or die from all causes compared with African Americans who attended a health education class over more than five years, according to new research published in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes.

Those practicing meditation also lowered their blood pressure and reported less stress and anger. And the more regularly patients meditated, the greater their survival, said researchers who conducted the study at the Medical College of Wisconsin in Milwaukee.”

I believe the major benefit of the interventional program was from the stress reduction and the elimination of three major dietary sources of trouble (trans-fats, excess omega 6 fats from processed-refined vegetable oils, and refined carbohydrates-sugar)

I have already discussed in other posts the problems associated with excess omega 6 fats and refined carbohydrates-sugar relative to cardiovascular risk. (9,10,11)

There is little controversy that elimination/reduction in trans-fats produces benefit. (12,13,14)

All three of these changes were essential to the whole foods approach of the intervention group.

I have also discussed the lack of data to support the contention that saturated fat from animal sources of protein contributes to cardiovascular disease. (15, 16))

I remain a strong proponent of a whole foods diet that includes a variety and abundance of organic vegetables and fruits, nuts, pastured grass-fed meat, fresh wild seafood, free-range organic poultry and eggs from that kind of poultry. This diet represents the foods we have evolved to eat, free from added sugar, hormones, antibiotics, pesticides. This dietary approach also produces a healthy balance of omega 6 to omega 3 fatty acid as well as a significant improvement in the ratio of potassium to sodium.

Stress reduction should be an essential part of our lives and data on this aspect of health will be discussed in future posts. References for this discussion appear below.

Peace,

BOB Hansen MD

REFERENCES:

1. JAMA Network | JAMA | Intensive Lifestyle Changes for Reversal of Coronary Heart Disease

2. Intensive meditation training, immune cell telomerase activity, and psychological mediators.

3. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres.

4. A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.

5. Meditation Improves Endothelial Function in Metabolic Syndrome, American Psychosomatic Society (APS) 69th Annual Scientific Meeting: Abstract 1639. Presented March 10, 2011.

6. Alterations in brain and immune function produced by mindfulness meditation.

7. Adrenocortical activity during meditation.

8. Meditation may reduce death, heart attack and stroke in heart patients | American Heart Association

9. Polyunsaturated fat, Saturated fat and the AHA

10, Lose weight, control blood sugar, reduce inflammation

11. Sugar, a serious addiction

12. The negative effects of hydrogenated trans fats and what to do about them.

13. Trans fats in America: a review of their use… [J Am Diet Assoc. 2010] – PubMed – NCBI

14. FDA to Ban Trans Fats in Foods – US News and World Report

15. saturated fat | Practical Evolutionary Health

16. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease.

Addendum to lose weight, control blood sugar, decrease inflammation

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To those of you who have subscribed to my blog by e-mail, I must apologize that I hit the “publish button” by mistake before I completed the finished article. So if you would like to read the full article, please go to the website for the updated and completed version.

Thanks

Bob Hansen MD

Lose weight, control blood sugar, reduce inflammation

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The Duke University Lifestyle Medicine Clinic prescribes a nutritional program based upon a very simple concept, limit carbohydrate intake and multiple problems improve. This approach is so powerful in controlling blood sugar that diabetic patients must reduce their medication before adopting the nutritional program in order to avoid very low blood sugars.

Compared to a low-fat diet weight loss approach, it is better or equal on every measurement studied. Here is what happens on the carbohydrate restricted program when compared to a low fat diet (American Heart Association diet). The carbohydrate restricted diet results in

Greater reduction in weight and body fat
Greater reduction in fasting blood sugar
Reduction in the amount of saturated fat circulating in the blood despite a higher intake than a low fat diet
Greater reduction in insulin with improved insulin sensitivity
Reduction in small LDL (low fat diets increase small LDL which is considered to be associated with more heart attacks and strokes)
Increase in HDL (low fat diets decrease HDL, decreased HDL is associated with increased risk of heart attack and stroke)
Greater reduction in Triglycerides
Reduction in the ApoB/ApoA-1 ratio (low fat diets do the opposite, and the opposite is considered to increase risk of heart attack and stroke).
Reduction in multiple markers of inflammation
Spontaneous reduction in caloric consumption without counting or restricting calories (people automatically eat less as a result of restricting carbohydrates, low-fat diets require counting and restricting calories in order to lose weight)
Increased consumption of non-starchy vegetables

All of these beneficial effects are accepted by the medical community as reducing cardiovascular risk .

The improved metabolic outcome can occur even without weight loss simply by substituting fat for carbohydrate.

“The key principle is that carbohydrate, directly or indirectly through the effect of insulin, controls the disposition of excess dietary nutrients. Dietary carbohydrate modulates lipolysis, lipoprotein assembly and processing and affects the relation between dietary intake of saturated fat intake and circulating levels.” see here

Yet despite these proven effects, the proponents of low-fat diets refer to the carbohydrate restriction approach as a “fad diet”. In his excellent discussion of this term, Richard Feinman points out that historically, a carbohydrate restriction approach is actually the longest standing and proven approach to the treatment of obesity compared to a low-fat diet which is a relative newcomer. He describes how a low-fat diet more closely meets the dictionary’s definition of a “fad”.

Multiple Studies have compared carbohydrate restriction to low fat diet approaches and the results are consistent. In addition to the advantages cited above, carbohydrate restricted approaches when compared to low-fat diets reveal that symptoms of “negative affect and hunger improved to a greater degree” compared with those following a low fat diet”. (see here)

When one analyzes the carbohydrate restricted diet (CRD) approach employed by many centers, including the Duke Interventional Medicine Clinic, one finds great similarity to a paleolithic diet.

They both eliminate or dramatically reduce

sugar-sweetened foods and beverages,
grains, flour foods and cereal foods
legumes (paleo completely, CRD to a large extent)
processed-refined vegetable oils
dairy (paleo completely, CRD to a large extent)

Fruits under a CRD are limited to small amounts of berries initially and this is liberalized over time as weight loss is achieved and metabolic parameters are improved. This is consistent with a paleolithic approach that recognizes that fruits and vegetables grown today have been bred to provide much higher sugar and starch content compared to the pre-agricultural fruits and vegetables that early hominids consumed for hundreds of thousands of years.

A carbohydrate restricted nutritional approach to treat obesity, diabetes, or metabolic syndrome appears to be a valid and arguably superior remedy to a growing problem in the developed world. Yet despite this strong and convincing scientific data, dietary fat-phobia has impaired the utilization of this proven therapeutic modality.

Peace,

Bob Hansen M.D.

Sugar II

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In my first post about sugar I discussed increased cardiovascular risk associated with consumption of added sugar, sweetened foods and beverages. This post will discuss other risks including childhood obesity and adult obesity, diabetes and Metabolic syndrome.

The marketing efforts directed at young children by soda producers and fast food restaurants is astounding. You can view a video produced by a concerned mother here.

Some highlights of the video include:

1:14 How her daughter’s obsession with one particular person made her realize what was happening.
2:20 Can you guess how much money the food industry spends marketing to kids?
3:15 There’s even a term for the way they make children more annoying.
3:55 Find out just how many thousands of ads kids see if they watch a regular amount of television.
4:30 Here’s why just turning off the TV isn’t a solution.
4:50 Learn which school supplies are now sponsored by junk food.
5:54 Find out how companies like Coca-Cola and Pepsi are straight-up conning school communities to buy their products.
6:47 Here’s what she finds most upsetting.
8:10 And here’s how they get even more information about kids.
9:30 She talks about the life and death consequences that hang in the balance with this issue.
10:24 We’re seeing the most depressing innovations in health care now thanks to the food industry.
12:00 You’ll never believe where McDonald’s wanted to advertise.
13:01 Find out who’s fighting these food behemoths and saving generations to come.

So what’s all the fuss? Where is the data to support a connection between sweetened beverages, sweetened foods and obesity, diabetes and metabolic syndrome?

Let’s start with a study by Gitanjali Singh and associates from Harvard School of Public Health reported here, the Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions. I read about this on Medscape published on-line. You must establish a user name and password to access these reviews, written for physicians and health professionals.

They reported that drinking large amounts of sugar sweetened beverages (SSBs) was associated with an increased body-mass index (BMI). Increased BMI is associated with deaths from diabetes, cardiovascular disease and cancer, so the authors calculated deaths associated with consumption SSBs from diabetes, CVD and cancer.

The researchers found that in 2010

“132,000 deaths from diabetes, 44,000 deaths from CVD, and 6000 deaths from cancer in the world could be attributed to drinking sugar-sweetened soft drinks, fruit juice, or sports beverages.”

“As part of the Global Burden of Disease study, the researchers obtained data from 114 national dietary surveys, representing more than 60% of the world’s population.

Based on data from large prospective cohort studies, they determined how changes in consumption of sugary drinks affected BMI, and next, how elevated BMI affected CVD, diabetes, and 7 obesity-related cancers (breast, uterine, esophageal, gallbladder, colorectal, kidney, and pancreatic cancer). Using data from the World Health Organization, they calculated the number of deaths from BMI-related CVD, diabetes, and cancer for men and for women aged 20 to 44, 45 to 64, and 65 years and older.”

Mexico had the highest number of deaths and Japan the lowest number of deaths attributed to the risk factor of sweetened beverage consumption. The USA had an estimated 25,000 deaths per year associated with drinking sugar sweetened beverages.

Medscape quoted Rachel K. Johnson, Ph.D. an AHA spokesperson.

“The evidence base that sugar-sweetened beverages are associated with excess weight gain is well established; what these investigators have done is to take it a step further by saying the excess weight gain that is attributable to sugary drinks actually increases the risk of death from diabetes, CVD, and cancer,”

The obesity literature is in agreement that consuming beverages with calories does not result in a decrease in an equivalent amount of calories from solid food consumption. In fact studies of humans demonstrate that sugar sweetened beverages increase the total amount of calories consumed by an amount equal to the calories in the beverage. This is added calories that do not produce satiety. This is why my Manifesto recommends drinking only water, coffee, tea, and no sweetened beverages.

Here is a discussion about sugar added beverages vs sweetened solid foods.

Consumption of Added Sugars from Liquid but Not Solid Sources Predicts Impaired Glucose Homeostasis and Insulin Resistance among Youth at Risk of Obesity.

“a higher consumption (10 g/d) of added sugars from liquid sources was associated with 0.04 mmol/L higher fasting glucose, 2.3 pmol/L higher fasting insulin, 0.1 unit higher homeostasis model assessment of insulin resistance (HOMA-IR), and 0.4 unit lower Matsuda-insulin sensitivity index (Matsuda-ISI) in all participants (P < 0.01).”

Translation, just 10 grams (1/3 ounce) of added sugar from beverages increased fasting blood sugar, increased fasting insulin, worsened Insulin resistance. Insulin resistance is the precursor to diabetes. This is a chronic inflammatory state.

How much sugar is in a can of coke? Look here. How Much Sugar in Sodas and Beverages? 39 grams in a 12 oz bottle of coke, 79 grams in a 7-Eleven 32 oz Big gulp, 128 grams in a 7-Eleven 44 oz Super Gulp. 77 grams in a 20 oz bottle of Mountain Dew, But it only takes 10 grams a day to cause harm.

” liquid added sugars were a risk factor for the development of impaired glucose homeostasis and insulin resistance over 2 y among youth at risk of obesity.”

But let’s look at another study.

A meta-analysis published in 2010 reported that consumption of just one or two sugar-sweetened beverages per day is associated with a 26% greater risk of developing type 2 diabetes and a 20% increased risk of developing metabolic syndrome. Abstract

They concluded:

“In addition to weight gain, higher consumption of SSBs (sugar sweetened beverages) is associated with development of metabolic syndrome and type 2 diabetes. These data provide empirical evidence that intake of SSBs should be limited to reduce obesity-related risk of chronic metabolic diseases”

Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: A meta-analysis. Diabetes Care 2010: 33:2477–2483.

At the time of this study publication, cities and states were introducing legislation for “soda taxes” on sugar-sweetened beverages. There were also attempts to make sodas and sugar drinks ineligible for food stamp purchases. See the discussion here.

That same year the American Journal of Clinical Nutrition published a study Carbohydrate quantity and quality and risk of type 2 diabetes in the European Prospective Investigation into Cancer and Nutrition–Netherlands (EPIC-NL) study

We investigated the associations of dietary glycemic load (GL), glycemic index (GI), carbohydrate, and fiber intake with the incidence of type 2 diabetes.

They followed 37,846 participants for a mean follow up period of 10 years.

They concluded:

“Diets high in GL, GI, and starch and low in fiber were associated with an increased diabetes risk. Both carbohydrate quantity and quality seem to be important factors in diabetes prevention. “

There is plenty of low quality carbohydrate in the sodas featured above. And there is no fiber to slow the absorption of the sugar. You might as well start an IV and deliver 128 grams of super-gulp sugar directly into the blood.

In 2010 a Health Policy Report concerning the consumption of sweetened beverages was published in the New England Journal of Medicine.

The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages – NEJMhpr0905723

They open up by stating:

The consumption of sugar-sweetened beverages

has been linked to risks for obesity, diabetes,

and heart disease.

A meta-analysis showed positive associations between intake of sugar-sweetened beverages and body weight-associations that were stronger in longitudinal studies than in cross-sectional studies and in studies that were not funded by the beverage industry than in those that were.

They go on to discuss how a meta-analysis funded by the beverage industry was interpreted as showing no evidence of an association between consumption of sugar-sweetened beverages and body weight,

“but it erroneously gave large weight to several small negative studies: when a more realistic weighting was used, the meta-analysis summary supported a positive association”

The authors site several studies linking sugar sweetened beverages to obesity in children and adults. Please click on the link above and go to page two for charts demonstrating the historical trend in sugared beverage consumption.

Since that publication multiple studies, discussions and policy statements have appeared in the medical literature. If you perform a PubMed search with “tax AND sugar” you will get 8 pages of citations. Here are some of them.

Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis.

This one concluded that:

Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity.

More studies from the search “sugar AND tax”.

Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study.

A substantial tax on sugar sweetened drinks could help reduce obesity.

Building a strategy for obesity prevention one piece at a time: the case of sugar-sweetened beverage taxation.

The potential impact on obesity of a 10% tax on sugar-sweetened beverages in Ireland, an effect assessment modelling study.

The sugar-sweetened beverage wars: public health and the role of the beverage industry.

A typology of beverage taxation: multiple approaches for obesity prevention and obesity prevention-related revenue generation.

Taxing sugar-sweetened beverages: the fight against obesity.

Sugar tax and obesity.

Intended and unintended consequences of a proposed national tax on sugar-sweetened beverages to combat the U.S. obesity problem.

Despite all of this discussion there has not been a “sugar tax” on sweetened beverages and here are several reasons.

Taxes on sugar-sweetened beverages: results from a 2011 national public opinion survey.

“Consumption of sugar-sweetened beverages including non-diet sodas, sport drinks, and energy drinks has been linked with obesity. Recent state and local efforts to tax these beverages have been unsuccessful. Enactment will be unlikely without public support, yet little research is available to assess how to effectively make the case for such taxes.

The objectives were to assess public opinion about arguments used commonly in tax debates regarding sugar-sweetened beverages and to assess differences in public opinion by respondents’ political party affiliation.

Findings indicated greater public agreement with anti- than pro-tax arguments. The most popular anti-tax argument was that a tax on sugar-sweetened beverages is arbitrary because it does not affect consumption of other unhealthy foods (60%). A majority also agreed that such taxes were a quick way for politicians to fill budget holes (58%); an unacceptable intrusion of government into people’s lives (53.8%); opposed by most Americans (53%); and harmful to the poor (51%). No pro-tax arguments were endorsed by a majority of the public. Respondents reported highest agreement with the argument that sugar-sweetened beverages were the single largest contributor to obesity (49%) and would raise revenue for obesity prevention (41%).”

So the relationship between sugar sweetened beverages and diabetes, obesity and metabolic syndrome seems well established but as a public policy issue there has been no traction on taxation remedies. And as the video above demonstrates, Coke and Pepsi have more than a foot in the door in our school systems and our homes (TV adds).

You can make a difference. vote here Tell the Soda Industry to Use Their Influence to Combat Childhood Obesity

A future post will discuss artificial sweeteners (diet beverages) which unfortunately also have a dismal track record.

Until next time,

Peace

Bob Hansen MD

An Egg a day keeps the doctor away

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When I recommend to my patients that they should eat eggs and vegetables for breakfast rather than breakfast cereals (which have high sugar content and nasty gut inflaming gluten proteins) they often ask “well what about my cholesterol ?”. I tell them that eggs are a health food and that they do not need to worry about their cholesterol.

I first read about the man who ate 25 eggs per day for 15 years here.

Health Correlator: The man who ate 25 eggs per day: What does this case really tell us?

He was 88 years old when some cholesterol fearing physicians studied his plasma lipids (HDL, LDL, triglycerides etc.) and other aspects of his health (blood pressure, weight, etc.) and discovered that he was very healthy at the ripe age of 88.

Normal Plasma Cholesterol in an 88-Year-Old Man Who Eats 25 Eggs a Day — NEJM

This article was published in 1991 and the authors concluded that this man was exceptional in lacking adverse health consequences from eating 25 fat and cholesterol laden eggs every day for 15 years. Since that time, many studies on the health effects of eggs have demonstrated that they are in fact a health food and do not increase cardiovascular risk. In fact they provide a nutrient dense assortment of important vitamins, minerals, fat, and protein. Perhaps most importantly they are very high in choline, an important nutrient which is not hard to come by. Eggs and liver provide an abundance of choline.

Choline is widely used in the human body for many important functions. These include:

building block for an important neuro-transmitter called acetyl-choline (you cannot live without it)
essential component of the phospholipids that form the outer membrane of all living cells
chemical precursor to betaine which is essential to health, particularly for eyesight
methyl metabolism (methylation is an essential physiologic chemical process in our body)
protects against fatty liver disease

You can read more about the importance of choline here:

Choline – Wikipedia, the free encyclopedia

Regular egg consumption has been demonstrated to improve insulin sensitivity and cardiovascular risk profiles in healthy individuals and in individuals with metabolic syndrome as demonstrated here:

Whole egg consumption improves lipoprotein profil… [Metabolism. 2013] – PubMed – NCBI

Daily egg consumption with modest carbohydrate restriction in that study resulted in:

improved insulin sensitivity (good)
reduction in oxidized LDL (very good, oxidized LDL is the major instigator for atherosclerosis)
reduced triglycerides (high triglycerides are a marker for metabolic syndrome, precursor to diabetes, heart attack and stroke)
reduction in other blood lipid markers for cardiovascular risk (apoE, apoC-III, large VLDL, total IDL, small LDL and medium LDL)
increase in the size of HDL and LDL particles (reduction in cardiovascular risk)

They concluded that:

“Atherogenic dyslipidemia improved for all individuals”

In adults with metabolic syndrome (hypertension, insulin resistance, obesity, high triglycerides) three whole eggs per day with moderate carbohydrate restriction resulted in:

reduced waist size
reduced % body fat
reduction in inflammation as measured by plasma tumor necrosis factor alpha and serum amyloid

The authors concluded that:

“on a moderate carbohydrate background diet, accompanied by weight loss, the inclusion of whole eggs improves inflammation to a greater extent than yolk-free egg substitute in those with MetS.”

Effects of carbohydrate restriction a… [J Clin Lipidol. 2013 Sep-Oct] – PubMed – NCBI

In yet another study:

Daily intake of 3 whole eggs, as part of a CRD, increased both plasma and lipoprotein lutein and zeaxanthin. Egg yolk may represent an important food source to improve plasma carotenoid status in a population at high risk for cardiovascular disease and type 2 diabetes.

See for yourself:

Egg intake improves carotenoid status by increasi… [Food Funct. 2013] – PubMed – NCBI

In another study:

Consumption of 2 and 4 egg yolks/d for 5 wk increases macular pigment concentrations (lutein and zeazanthin) in older adults with low macular pigment taking cholesterol-lowering statins.

“Lutein and zeaxanthin may reduce the risk of dry, age-related macular degeneration because of their photo-oxidative role as macular pigment.”

Consumption of 2 and 4 egg yolks/d for 5 wk i… [Am J Clin Nutr. 2009] – PubMed – NCBI

Studies of the benefits of high-cholesterol egg consumption have been so convincing that even the American Heart Association has removed advice to avoid eggs.

“…there have been a number of epidemiological studies that did not support a relationship between cholesterol intake and cardiovascular disease. Further, a number of recent clinical trials that looked at the effects of long-term egg consumption (as a vehicle for dietary cholesterol) reported no negative impact on various indices of cardiovascular health and disease”

Exploring the factors that affect blood cholesterol… [Adv Nutr. 2012] – PubMed – NCBI

From an evolutionary medicine point of view, eggs and ample dietary cholesterol have been around a long time in the human diet.

“Paleoanthropologists suggest that dietary cholesterol has been in the human diet for millions of years (7–10). Sources included eggs, bone marrow, and organ meats. Stone Age intake of cholesterol is uncertain, but it may well have exceeded current dietary recommendations.

There are many important biological roles for cholesterol that span the spectrum from cell membrane structure to steroid hormone synthesis, bile acid synthesis, and others. The vital role of cholesterol in human metabolism and the well-established place of dietary cholesterol in the native human diet provide a robust theoretical challenge to the view that dietary cholesterol poses a threat to human health.

More important still are prospective, population-based studies that, when similarly scrupulous about variation in other dietary components, find no association between cholesterol intake in general, or egg intake in particular, and the risk of CVD (13).”

Exploring the factors that affect blood cholesterol… [Adv Nutr. 2012] – PubMed – NCBI

Here are more links to discover that eggs are a health food.

Egg consumption and endothelial function: a randomized controlled crossover trial.

Endothelial function testing as a biomarker of vascular disease.

Daily egg consumption in hyperlipidemic adults–effects on endothelial function and cardiovascular risk.

Endothelial function testing as a biomarker of vascular disease.

Daily egg consumption in hyperlipidemic adults–effects on endothelial function and cardiovascular risk.

High intake of cholesterol results in less atherogenic low-density lipoprotein particles in men and women independent of response classification.

Plasma LDL and HDL characteristics and carotenoid content are positively influenced by egg consumption in an elderly population.

Eggs distinctly modulate plasma carotenoid and lipoprotein subclasses in adult men following a carbohydrate-restricted diet.

Significance of small dense low-density lipoprotein-cholesterol concentrations in relation to the severity of coronary heart diseases.

Rethinking dietary cholesterol. [Curr Opin Clin Nutr Metab Care. 2012] – PubMed – NCBI

Endothelial function is the term used to describe how well the arteries can expand and contract to meet the needs of blood flow. It is considered an important tool for assessing cardiovascular risk and it is impaired in metabolic syndrome, diabetes and in patients with coronary artery disease. Compromise of endothelial function is part of the process of atherosclerosis and heart attacks.

“There is thus a case to be made that endothelial function is potentially a summative measure of overall cardiac risk status and at least a valuable addition to standard risk measures (45). The ever-expanding footprint of research in this area in the cardiology literature attests to its importance.”

Despite (or because of) their high fat and cholesterol content, eggs have not been found to have any negative effects on endothelial function.

Rethinking dietary cholesterol. [Curr Opin Clin Nutr Metab Care. 2012] – PubMed – NCBI

So far since launching this blog a few weeks ago we have discovered that saturated fat and cholesterol containing foods are not the villains portrayed by the media, doctors and professional organizations that give us nutritional advice.

We have reviewed evidence that added sugar, sweetened beverages, refined carbohydrates (especially flour foods), trans-fats, and excessive polyunsaturated omega six fats from processed “vegetable oil” are the culprits with regards to obesity, diabetes, heart attack and stroke. These culprit components of the modern Western diet were definitely absent from the diets of our paleolithic ancestors. We have not evolved to tolerate them. These modern manufactured and processed “foods” represent an unhealthy deviation from our evolutionary past.

There is so much more to discuss. In the spirit of more work ahead during this 50th anniversary week of John F Kennedy’s assassination. I will close with a quote from JFK’s favorite poet and friend, Robert Frost.

“I have promises to keep, / And miles to go before I sleep, / And miles to go before I sleep.”

Peace,

Bob Hansen MD

Introduction

Practical Evolutionary Health

Americans spend almost twice as much per person on health care than the rest of the developed world yet we rank between 20 and 30 on most measures of public health. Why is that? The answer lies in our cultural habits, shaped in no small part by the marketing departments and sales forces of corporate America. Lifestyle and personal habits, in the broadest sense, determine our longevity and functional status (both physical and mental) as we age more than any drug or surgery. Dissecting how corporate America shapes and affects our health requires us to explore several layers. The first layer includes the food, pharmaceutical and medical device industries. But looking deeper at what shapes our culture and therefore our health, we must recognize the way our consumer driven economy shapes our culture with regard to the essential ingredients of health and disease.

This blog will explore the science and economics of health in an attempt to answer the “why is that?” above. The framework of this exploration will utilize a practical evolutionary-medicine perspective.

For a few million years our ancestors lived as hunter-gatherers. That period represents more than 99% of our evolutionary history. During that period our sleep habits cycled with the sun, we exercised regularly to obtain food, we ate fresh foods that included wild game and seafood, berries, nuts, tubers and some wild plants, we rested allot, and enjoyed the benefits of small intimate social networks. After a few million years evolving in that manner we introduced agriculture, bred grass seeds into grains, bred wild fruits and vegetables into a variety of agricultural products with very different nutritional profiles as compared to the wild predecessors, and domesticated animals. Beyond that, we entered a period of industrialization that has altered our eating, sleeping, social and exercise habits in a profound and detrimental manner.

Convenience foods have been engineered in human laboratories to present flavors, textures, appearances and just the right mix of sugar-salt-fat to stimulate excessive consumption of nutritionally deplete calories. Mono-agriculture has depleted our soil both quantitatively and qualitatively. Corporate farming and animal husbandry have introduced the unnecessary and harmful use of antibiotics, hormones, insecticides and pesticides in the name of efficiency. Shift factory work has disrupted the circadian rhythm of millions of workers, increasing the risk of cancer, diabetes, obesity, depression and accidents to name a few. Artificial light has interfered with the procurement of adequate restorative sleep so essential for health. And modern society has depleted our social network of meaningful supportive relationships and meaningful work.

That is the big picture, but what is the scientific data to support these statements? And what can we do to recapture the essential ingredients of healthy living while bringing home a paycheck? That is what this blog is about.

The Manifesto page represents a summary opinion of important topics related to health.

My posts will generally address topics covered in the Manifesto.

Bob Hansen MD

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