Tag Archive for: cardiovascular disease

Food or Supplements?

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One of the changes I’ve made in selecting topics to write about in these Memos is to read the table of contents of the scientific journals to which I subscribe, especially the nutrition journals. It’s easier to see what’s controversial by looking at news feeds, but they miss a lot of positive nutrition science. One question that’s ever-present is this: when it comes to nutrients, is getting nutrients from supplements as good as getting nutrients from food?

Researchers searched four databases of scientific journals to find randomized-controlled trials that examined the effect of either polyphenol-rich foods or polyphenol extracts on risk factors for cardiovascular disease (CVD). It’s estimated that there are more than 8,000 types of polyphenols, including flavonoids, polyphenolic amides, phenolic acids, resveratrol, and ellagic acid. You’ll find polyphenols in fruits, vegetables, spices, herbs, teas, nuts, and seeds.

They found over 1,100 studies that fit the profile. Using subject, statistical, and nutrient criteria, they whittled the number of studies down to 46. Then they conducted a meta-analysis of the impact of food and supplements on the following CVD risk-factors: systolic BP, diastolic BP, endothelial function, fasting blood glucose, total-, LDL-, and HDL-cholesterol, C-reactive protein, Il-6, and waist circumference.

Nutrition studies are usually messy, and this one was no exception. I spot-checked the 46 studies and found different foods for the polyphenol sources and different extracts for the supplements. Still, it was as well-done as such a study could be. I’ll give you the results on Saturday.

Tomorrow night is the Insider Conference call for March. The topic is the absorption of omega-3s, and I’ll also answer your questions. Become an Insider by 8 p.m., and you can participate in this live event.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.sciencedirect.com/science/article/pii/S2161831323000029

Why Are You Napping?

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I think people get frustrated with research because, just like I’ve described this week, one study says one thing while another comes to different conclusions. I hope that if you’ve been reading the Memo long enough you won’t be frustrated. In this case, why might studies that seem similar on the surface come up with different results?

First, while the studies seemed to ask the same questions, the studies actually had different objectives. In the Swedish study that showed a reduction in cardiovascular disease (CVD) events for those napping once or twice a week, the subjects were selected because they had not had any cardiac events or diagnosis of CVD. That means that any CVD that took place in the follow-up period was a primary event. In the other two studies, high-risk CVD events were excluded in one but other CVD factors were allowed such as hypertension.

Second, the purpose of the Swedish was designed to look at the development of CVD. The other two studies from Switzerland and the U.K. recruited over 500,000 subjects, but the research questions appeared to be decided after the studies began. There’s nothing wrong with that, but just because you have collected data on many variables, including genetics, doesn’t mean the data collected answer the research questions that were asked.

For example, the premise was that daytime napping causes CVD and hypertension. It seems likely that those conditions could cause fatigue, which would require daytime napping. Even if that were not the case, the subjects appeared to already have problems sleeping, which would impact hormone levels that contribute to CVD such as cortisol levels and many others.

The Bottom Line

These large studies attempted to make sense out of prior research that showed a link between daytime napping and CVD. What I think these studies demonstrate is that the cause of the nap is important. If it’s a planned nap designed to allow digestion or a pause in a long work day, it may not be hazardous to your heart health. However, if a person doesn’t sleep well or has sleep apnea and is fatigued because of that, being forced to nap during the day to recover can indicate a higher risk of developing CVD and hypertension.

Diet, body mass, lack of exercise, and other factors all have a role to play in sleep quality and CVD as well. If you plan your nap, you’re in control. If you’re forced to nap, time to look at your lifestyle and see what you can change.

What are you prepared to do today?

        Dr. Chet

P.S. Just for fun, these are a few of Riley’s more inventive napping positions. Oh, to be that flexible! Maybe the monkey blanket helps.

References:
1. Heart. 2019;105:1793–1798.
2. J Am Heart Assoc. 2022;11:e025969. DOI: 10.1161/JAHA.122.025969.
3. Hypertension. 2022;79:00–00. DOI: 10.1161/HYPERTENSIONAHA.122.19120.

To Nap or Not to Nap

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About 16 years ago, Paula and I spent several weeks (spread out from March to October) helping our son Matthew build his boat-building shop. The daily routine went something like this: start early, break for lunch, take a 30- to 45-minute nap, then work the rest of the day. Matthew and Kerri live near Charleston, SC, where summer temperatures aren’t really conducive to construction work, so napping during the hottest part of the day made a lot of sense, but we also found we got a lot more accomplished every day.

I’ve used that approach off and on ever since. Recently, a couple studies were published that called into question whether naps were a good idea as they might be related to cardiovascular disease (CVD).

The research news caught my attention because the last time I read a research paper about sleep and napping showed that there was no relationship between napping and cardiovascular disease. In fact, the risk over five years of follow-up was a 42% decrease in CVD events when a person took a nap once or twice a week and no risk if a person napped every day (1).

In the most recent research, there was a relationship between napping and hypertension and napping and CVD in two separate studies with thousands of subjects (2, 3). Why? We’ll delve into why there were different results on Saturday.

What are you prepared to do today?

        Dr. Chet

References:
1. Heart. 2019;105:1793–1798.
2. J Am Heart Assoc. 2022;11:e025969. DOI: 10.1161/JAHA.122.025969.
3. Hypertension. 2022;79:00–00. DOI: 10.1161/HYPERTENSIONAHA.122.19120.

The Secret to Prevention

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Consistency.

I thought I’d lead with the secret to disease prevention instead of making you wait. Whatever you want to accomplish in taking charge of your health, you have to be consistent. The polypill study proved it although the scientists, being conservative in their conclusions, don’t come out and say it—but I will. Here’s why.

Why the Polypill Was the Difference

The subjects taking the polypill were more consistent in taking their medications than the subjects who took the exact same medications as individual pills. They didn’t ask the subjects whether it was easier to remember to take one versus three pills; that could be a factor as the mean age of the subjects was over 75. It’s also easier to keep one medication refilled rather than three. Whatever the reason, the subjects just took their medication on a more regular basis and thus saw a decrease in recurrence of cardiovascular disease events.

While this was a study about medication, it applies to reducing or changing your foods to eat healthier, reducing the risk of cardiovascular disease and diabetes, or any other health goal: we have to be consistent. Even getting a health benefit from taking a supplement requires you to take it regularly for weeks or months to see a benefit.

Weight Loss: A Special Case

Losing weight and maintaining the weight loss is the single most difficult thing humans can do. I know. I’ve been trying for decades. I don’t weigh what I used to weigh, but I’m not where I want to be. I know many of you are in that spot as well.

It’s not the losing that’s the problem—it’s the maintaining. When you consider the simplicity of it, why is it so difficult to sustain a way of eating that keeps you at a healthy weight? Scientists and physicians have examined genetics, proteomics, hormones, and more. They have looked at every psychological issue they can think of to try to help people lose the weight and keep it off. No luck so far.

I’ll go out on a limb and predict there won’t be any one answer. It’s really up to each individual to find a way to eat that can sustain a normal body weight. It will probably be slightly different for each of us as to the types of foods and exercise we use, but our solution exists. We just have to find a way to be consistent and in the case of weight loss, it has to be for life.

The Bottom Line

We face plenty of obstacles in our path to health. We may not have the best genes. We may have had a poor lifestyle for many years that we have to compensate for. We may not have all the resources we need. But if we can pick a couple of things at a time and make them our habits for life, we can begin the process. We just have to be consistent, day in, day out. Where we end up may not be perfect, but it can be better than you are right now. That’s what aging with a vengeance is all about.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2022. DOI: 10.1056/NEJMoa2208275

Will the Polypill Reduce Second Heart Attacks?

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One of the issues with prevention is having people stick to a plan, even after an event as serious as a heart attack. Lifestyle changes are challenging to stick with, but so is something as simple as taking medications. Remember, this isn’t to prevent a heart attack; it’s to prevent a second one. That’s serious.

The concept of a polypill has been around for close to 15 years. The idea was to put medications together in one pill as a preventive that would reduce the risk of getting cardiovascular disease. For a long time, that idea never went anywhere, but recently researchers decided to resurrect the concept. This time, the objective was to monitor subjects with recent heart attacks. Would there be a difference in the rate of secondary events between subjects who took the polypill and those who took the same medications as individual pills? The medications used were aspirin, ace-inhibitor, and a statin. After three years of follow-up, the subjects in the polypill experienced significantly fewer secondary events, 9.5% versus 12.7%.

Can you figure out why the subjects who took the polypill did better than the subjects who took the same medications individually? I’ll tell you the secret to disease prevention on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2022. DOI: 10.1056/NEJMoa2208275

Science Says Coffee Is Good

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Research is based on curiosity; in order to do good research, you have to ask good questions. Researchers in the coffee study asked: Will a little sugar negate the benefits from drinking coffee? We don’t know whether this was the initial question or if researchers wanted to find out whether artificial sweeteners might have negative effects that altered the benefits of plain coffee.

Turns out artificial sweeteners did not have an impact on the mortality of those who used it over the seven years of the observational study. If you drink from one to 4.5 cups of unsweetened or sweetened coffee, there’s a reduction in mortality from CVD and cancer.

If artificial sweeteners did have an impact on mortality, the headlines would have been bigger than they were. Last week’s look at the safety of melatonin for kids led me to ask the author “Why melatonin?” Multiminerals in gummy form generally contain iron, and that can be toxic to toddlers in high quantities. So why not start looking there and then examine other nutrients? To date, I haven’t gotten an answer.

What Do We Mean by “Coffee?”

I explained how I drink my coffee earlier in the week. However for today’s coffee drinkers, there could be high-sugar flavors added as well as whipped cream and other assorted milks. It seems like a science unto itself to know how to order some of the “coffees” available today, let alone fill those orders. Based on what I read in the Methods section, the questionnaire they used didn’t go into that kind of detail. Extra sugar and fat from elaborate coffees may have a negative impact that won’t be determined in this study.

The Bottom Line

This was an observational study, so there’s no cause and effect implied. Still it’s good to know that the cup o’ Joe isn’t doing any harm and may actually be good for you. Now, about those tea drinkers…

What are you prepared to do today?

        Dr. Chet

Reference: Ann Internal Med. 2022. https://doi.org/10.7326/M21-2977

Coffee: One Sugar Please

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I have a strong relationship with coffee. I began drinking coffee when my mother put coffee in a bottle with a little sugar for me when I was a toddler. These days, a mother would get reprimanded by somebody if she did such a thing, but in the 1950s there weren’t the variety of drinks for children that are available today; milk, orange juice, and Kool-Aid, that was about it.

When I talk about coffee now, I don’t mean the fancy kind with steamed milk and espresso and other ingredients. I drink strong coffee, eight to ten ounces per mug, with exactly one teaspoon of sugar. I drink only Sumatra roast and use a Turkish grind, which is more like powder than grounds; I get the most flavor out of the beans when I brew it that way. I sit back and drink it, savoring every sip. (And yet somehow I married a woman who thinks the only thing coffee is good for is dipping a biscotti.)

The benefits of coffee have been established in prior studies of coffee drinkers compared to non-coffee drinkers. Coffee seems to reduce mortality from cardiovascular disease and cancer. No one seemed to separate the drinkers who used sweeteners from those who didn’t, and that’s why a recently published study caught my attention.

Researchers examined data from over 170,000 subjects in the U.K. Biobank Study; their purpose was to see if adding sweeteners to coffee, either sugar or artificial sweeteners, impacted the mortality of the subjects. I won’t make you wait until Saturday: the coffee sweetened with sugar had the same reduction in mortality as the unsweetened coffee. What about artificial sweeteners? I’ll talk about those on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Ann Internal Med. 2022. https://doi.org/10.7326/M21-2977

Should People with CVD Take Omega-3s?

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Last time, I talked about some research that hasn’t been done to definitively know whether DHA contributes to arrhythmias or not, but I implied that there may be one issue that may have contributed to this latest study. Let’s talk about research bias.

Research Bias

Some of the researchers who examined the data from the longitudinal study I talked about on Tuesday were also involved in at least one of the clinical trials on Vascepa, the pharmaceutical form of EPA-only omega-3s. I know what you’re thinking: somehow they intentionally manipulated data so that it seemed DHA was bad. I wouldn’t assume that, because these are good scientists. However, there has to be an inherent bias—beliefs that set up space in your brain and affect your actions without you realizing it. Another way of stating this would be that you find what you look for. It would be very difficult to examine any data involving EPA, DHA, and cardiovascular disease and withhold bias. I don’t believe it was intentional, but I also believe that it could have influenced the results to some degree.

The INtermountain Healthcare Biological Samples Collection Project and Investigational Registry (INSPIRE for short) is not a randomized clinical trial; it’s an observational study. I’ve already talked about the data that are missing on diet, supplementation, and exercise. In addition, it’s a big stretch to suggest that 10 years after samples were taken during an angiographic procedure that the same distribution of EPA-DHA was maintained.

Prior Research

Let’s think about the studies from last week: they were test-tube studies. Those are the foundation you must build before you start doing animal testing; only after that do you get to human testing. One research group also did a study on rodents which demonstrated proof of possible benefit. Have we had that type of research on EPA and DHA as it relates to cardiovascular disease? I did find some.

There have been studies examining how omega-3s may positively affect heart rhythms. In studies on rodents and dogs, DHA but not EPA showed clear benefits on reducing atrial fibrillation and other forms of cardiovascular disease.

But when you examine research on humans, the data are conflicting. By that I mean that some studies show that higher DHA intake and/or levels are associated with the reduction of arrhythmias. Other more recent research shows that it may not. There’s simply not enough information to make a decision.

The Bottom Line

At this point, you have to be thinking “What the heck am I supposed to do?” I think that we stand in an area of research where we have to “reserve judgment,” or maybe it would be better to say to “reserve condemnation.” We just don’t have enough data to make an informed decision either way. I’ve illustrated some of the things that need to be answered as it relates to omega-3 intake, but there are many more questions.

So I’ll leave you with this. If you have had no signs or symptoms of cardiovascular disease, no matter your age, you can most likely continue taking the same omega-3 supplements you always have been. If you have had a heart attack with damage to the muscle tissue, that seems to be where the problem lies, but it isn’t the same for every person. I would have a discussion with your cardiologist before deciding whether to take just EPA or to continue taking combinations of EPA and DHA; that’s the prudent thing to do.

But as you make that decision, consider all the other benefits of omega-3s. A search for “omega-3” at drchet.com yields several pages of results. Very rarely in life do we have simple decisions to make; it’s always a balancing act between competing objectives and imperfect information, and this is another one of those situations.

What are you prepared to do today?

        Dr. Chet

References:
1. J Am Coll Cardiol. 2021 May, 77 (18_Supplement_1) 1453.
2. Vascul Pharmacol. 2016 Jul;82:11-9. doi: 10.1016/j.vph.2016.03.007.
3. Can J Physiol Pharmacol. 2016 Mar;94(3):309-23. doi: 10.1139/cjpp-2015-0300.
4. Circulation: Arrhythmia and Electrophysiology. 2012;5:978–983.

Omega-3s and Heart Disease

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In addition to the research papers on omega-3s I talked about last week, another paper was presented at the American College of Cardiology in May that suggests EPA seems to reduce cardiovascular disease (CVD), while DHA seems to neutralize the benefits. Let’s take a look at this recent study to see what they found.

I haven’t seen the data, just press releases of varying lengths; I’ve written the authors but haven’t heard back yet. The problem with this recent study is that it’s a retrospective examination of a large group of people. The data are part of an ongoing study (much like the All Of Us study in which I’m a volunteer) that secured blood and tissue samples of volunteers; the researchers use that data as well as access to the volunteers’ medical records. In this case, they assessed the EPA and DHA levels of the blood samples and the CVD events that occurred in a random sample of the volunteers over the years. That’s how they determined that the EPA was beneficial in reducing CVD and as DHA levels rose, the benefits were negated.

The primary problem is that the blood samples are a snapshot of one day in the life of the volunteers. We have no idea if they took dietary supplements or if they happened to eat a lot of fish or a lot of nuts and other foods with omega-3s. No other dietary data, no supplement data, no exercise data—all things that we know are related to the development of cardiovascular disease. I think there’s a significant factor at play in this data analysis, and I’ll give you that observation in Saturday’s memo.

What are you prepared to do today?

        Dr. Chet

Reference: Press Release: Warning: Combination of Omega-3s in Popular Supplements May Blunt Heart Benefits. Intermountain Medical Center May 17, 2021

Omega-3s and A-Fib: More Analysis Required

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I hope that you took the time to review the paper on atrial fibrillation as well as the research letter on omega-3s and atrial fibrillation. If you haven’t, especially the primer on A-fib, please do it. It’s a serious condition that requires attention if you have it; in most cases, fixing it is surprisingly simple.

The research letter included five studies. I decided to look at each of those research papers individually to see how each trial was conducted, especially on the populations used in those experiments. Here’s what I found.

The Subjects

The subjects in the studies had several characteristics in common. First, they were, on average, in their mid 60s and older. Second, they had already had a myocardial infarction (heart attack) or were at high risk for cardiovascular disease due to factors such as obesity, hypertension, elevated triglycerides, and others. Third, most were taking multiple medications.

They definitely were not healthy and free of disease. The potential for a cardiac event increases if you’ve already had a cardiac event. On top of that, in the trials that used prescription fish oils, the attempt was to lower triglycerides in those patients who were taking a maximal dose of statins. There may be some interaction that hasn’t been identified yet between very high doses of omega-3s, equal to or greater than four grams, and statin medications or other pharmaceuticals the patients were taking to control blood pressure, heart rate, etc.

In short, this does not apply to everyone. In fact, in the concluding statement of the research letter, the researchers state that physicians should be cautious when prescribing high-dose omega-3s in patients with high triglycerides and an increased risk of cardiovascular disease.

Additional Analyses

As I alluded to in the prior paragraphs, I think the analysis should include factors such as exercise, diet, and especially prescription medications. It may be that the number of subjects might not be able to be broken down by statin intake, beta blocker intake, or ace inhibitors, but I think that it should at least be examined to see if there’s any trend.

Also, the data could be separated into those people who’ve had a heart attack and those that haven’t, even though they may have significant risk factors for cardiovascular disease. After a heart attack, there may be morphological changes such as damage to nerve conduction or the buildup of scar tissue that could impact how omega-3s impact the heart itself.

Are all of these possible? I would think it would be with over 150,000 subjects from all the studies included in the meta-analysis.

Two More Things

I still have not found a single nutritionist involved in any of this research. When you look at prior studies that seemed to benefit heart rhythms, it’s DHA omega-3, not EPA, which is the factor related to better heart rhythms.

Take a look at the map that’s in the primer on atrial fibrillation. It applies to those on Medicare who are 65 and older, but there’s an amazing and obvious trend. I’m even going to give it a name; I’ll tell you that next Tuesday. The only clue that I’ll give you is to think maps and what they’re typically used for.

The Bottom Line

While interesting, the Research Letter on the update of omega-3s in relation to atrial fibrillation leaves more questions than answers. So far, it applies only to people over 65 with high triglycerides and other risk factors for cardiovascular disease. If you already take omega-3 fatty acids, there’s probably no reason to stop, but it’s a discussion you should have with your physician.

It’s also obvious that if you do have high triglycerides, you can work on changing that by changing your diet first. Reducing refined carbohydrates is the key; eating more vegetables helps as well.

It always comes back to this: eat better. Eat less. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal – CVD Pharm. 2021 doi:10.1093/ehjcvp/pvab008
2. Curr Atheroscler Rep. 2020. https://doi.org/10.1007/s11883-020-00865-5
3. Atrial Fibrillation Primer. https://www.cdc.gov/heartdisease/atrial_fibrillation.htm