Tag Archive for: cardiovascular disease

Omega-3s and Cardiac Events

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There was another study this week on omega-3 fatty acids. While the study I talked about last Thursday was small with only 21 subjects, this trial contained over 13,000 subjects from 675 hospitals and clinical centers all around the world. In this five-year study, one of the omega-3 fish oil medications was being tested to see if it would reduce cardiac events such as heart attacks, stroke, and death when compared with subjects taking a corn-oil placebo. The study was stopped early when it was clear there were going to be no significant differences in any of the outcomes that were being studied. In other words, the prescription fish oil did not reduce cardiovascular disease events.

While that may seem disappointing, there are some factors that most likely impacted the outcome and a couple that may have but could not be tested.

The Subject Pool

The subjects in this clinical trial had significant risk for CVD; they were required to have established coronary artery disease or significant risk factors to be included in the clinical trial. Those risk factors included being a type 1 or type 2 diabetic, with at least one additional risk factor including chronic smoking, hypertension, hs-CRP higher than two mg/L, moderately increased protein loss, or being older with similar factors as the diabetics.

The Data Not Collected

In reading the study, there were three criteria that came to mind that could have impacted the outcome if the corresponding data had been collected and considered in the statistical analysis. I emailed the relevant author and got the answers.

1. Were data collected on exercise habits of the subjects? No.

2. Were nutritional data collected on the subjects? No.

3. Was the form of omega-3 used, a highly purified carboxylic acid form, assessed as to how the metabolism impacts the omega-3s’ mechanism of action? No.

It seems to me that if the data could be analyzed on exercisers versus sedentary as well as using nutritional factors, even just daily caloric intake, there may have been significant results. As for the form of omega-3s, the CA form is highly absorbed and doesn’t require a fat in the diet to assist with that process. There might have been something else that happens during metabolism that normally assists in the risk reduction. We just don’t know.

The Bottom Line

The authors acknowledge that this subject pool was at high risk for cardiac events. One explanation is that the progression of disease may have already been too advanced and could have impacted the efficacy of the medication. For people with less established CVD, the omega-3s might have been more effective.

Many in the medical field wrote about the failure of omega-3s in medication or supplement form to prove that they have any impact on CVD events or mortality. I think they’re wrong. The one outcome they never test is the quality of life. Granted, it’s difficult to assess but if people can live their lives even 10% better, regardless of CVD events, that seems worth it. Paula and I are still taking our omega-3 supplements; in fact Riley takes one, too, even though he’s only five and we’re not concerned about his heart. Whether you’re worried about your heart or not, omega-3s have many benefits. This study shows no reason why you or I should stop taking them.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA. 2020;324(22):2268-2280. doi:10.1001/jama.2020.22258

Research Update on Fish Oil Supplements

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Researchers performed a meta-analysis of studies that examined EPA and DHA as dietary supplements to see if there was a reduction in CVD events and mortality. In this study, researchers included 40 studies with 135,267 participants. While they examined many different variables, including whether EPA was better than DHA and whether they could find the best combination or ratio, almost every analysis they ran demonstrated benefits for those who use fish oil supplements: a 13% decrease in the risk of a heart attack, a 10% decrease in any coronary heart disease event, and a 35% reduction in the risk of a fatal heart attack.

For me, the most significant finding was that there was a dose-response effect of taking fish oil supplements. In other words, CVD events decreased with higher intake of fish oil supplements.

The Problems with the Prescription Study

There were three issues with the EVAPORATE study I talked about in Thursday’s Memo. First, there was a significant loss of subjects. Most of the loss was in the experimental group, which reduced the number of subjects from 40 to 31.

Second, they did not compare the prescription fish oil with an equivalent amount of fish oil dietary supplement, whether it contained DHA or not, which seems to be a glaring omission to me.

Finally, the study was funded by the manufacturer; several of the researchers had a relationship with the pharmaceutical manufacturer as well. That doesn’t mean anything shady was going on, but it does put in question the conclusions that can be drawn about the significance of the entire clinical trial.

The Problem with the Fish Oil Supplement Study

The primary problem with the fish oil supplement study is that it was a meta-analysis. Even though that method is becoming popular, and even though by all accounts the researchers tried their best in selecting the correct studies for inclusion, there’s always the specter that they may have left out some studies. To their credit, they re-ran the analysis without several of the clinical trials and did get slightly different findings. However, it did not change the outcomes related to heart attacks or coronary heart disease events.

The study was funded by Global Organization for EPA and DHA Omega-3s. Just as with the pharmaceutical study, there’s an inherent bias implied. In both cases though, if the funding organizations didn’t sponsor the research, who would? There are only so many research dollars available, and many dollars are being siphoned off to fund urgent COVID-19 studies.

The Bottom Line

I think that these studies establish that fish oil is beneficial to reduce CVD events and reduce disease progression. Because there appears to be a dose-response relationship to fish oil and the reduction of CVD risk, the higher amount of fish oil a person takes, up to four grams, the better the potential outcomes.

Which one is better: prescription versus supplements? Until there’s a study that directly compares prescription fish oil to fish oil supplements, I don’t believe it matters; both studies we reviewed demonstrate benefits. The key is that if you have been diagnosed with CVD, you should take fish oil. Talk it over with your physician first and then get going. Your heart will love you for it. And don’t forget to eat better and move more as well.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal (2020) 00, 1–8 doi:10.1093/eurheartj/ehaa652
2. https://doi.org/10.1016/j.mayocp.2020.08.034

Research Update on Prescription Fish Oil

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Let’s begin by taking a look at the prescription fish oil supplement medication. To review, this is a 100%-EPA fish oil that received FDA approval in December of 2019. The amount prescribed for people with high triglycerides is four grams of highly processed fish oil per day. Data from the REDUCE-IT trial suggested that there was a 25% decrease in mortality in the experimental group compared with the control group.

The current trial was called the EVAPORATE trial: Effect of Vascepa on Improving Coronary Atherosclerosis in People with High Triglycerides Taking Statin Therapy. The study began with 80 men and women, ages 30-85, with greater than 20% blockage in at least one of their coronary arteries, elevated triglycerides, and taking statin therapy; 68 subjects completed the 18-month study. The primary endpoint was to see if there was any reduction in plaque buildup in the coronary arteries.

The subjects in the prescription fish oil group saw a 17% decrease in overall arterial plaque; there was a plaque increase in the placebo group. The researchers did not track cardiovascular events or mortality in this study. We’ll take a look at the OTC fish oil supplement study on Saturday as well as determine the clinical significance of each trial.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal (2020) 00, 1–8 doi:10.1093/eurheartj/ehaa652
2. https://doi.org/10.1016/j.mayocp.2020.08.034

Research Update: Fish Oil and Heart Disease

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The prescription fish oil Vascepa has been approved since December of last year. The fish oil medication was originally intended for those who had a family history of high triglycerides of 500 mg/dl or greater. In the approval process, the recommendation was lowered to those whose triglycerides were at least 150 mg/dl and who were taking a statin medication. But the research hasn’t stopped.

Research on Vascepa as well as over-the-counter (OTC) fish oil supplements continues. From the pharmaceutical perspective, more research on the use of the medication could result in an increase in the potential applications of this pharmaceutical. From the dietary supplement perspective, research may help establish the efficacy of using fish oil dietary supplements instead of the prescription medication

Last week within one day of each other, studies on prescription fish oil and fish oil supplements were published that both demonstrated significant benefits. We’ll review those studies the rest of the week and see if we can find out whether fish oil dietary supplements match up with pharmaceutical fish oil. If you want a preview of the studies, check the references below; they’re both open access.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal (2020) 00, 1–8 doi:10.1093/eurheartj/ehaa652
2. https://doi.org/10.1016/j.mayocp.2020.08.034

Spice Up Your Life and Be Healthier

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Before I get into this memo any further, keep in mind there were only 12 subjects in this study, and we don’t change our recommendations for an entire society based on a limited numbers of subjects. We just have to recognize that this is a preliminary study. Second, because they examined a large number of variables, the probability of getting a false positive increases.

As long as we keep those in mind, the results were really surprising. Adding spices to a high-fat, high-carbohydrate meal reduced the inflammation caused by that meal. While coconut curry chicken might not be your preference, I’d wager you’ve eaten a bacon cheeseburger with fries and a soft drink at some point. That can easily add up to a similar profile of a high-fat, high-carbohydrate meal. So let’s take a look at the spices.

The Spices

The spice blend included the following spices, but not all dishes contained all the spices. For example, the turmeric was used in the chicken dish while the cinnamon was used in the biscuit:

Turmeric
Ginger
Cinnamon
Oregano
Parsley
Basil
Coriander
Cumin
Red pepper
Rosemary
Black pepper
Bay leaf
Thyme

This is not a magic blend by any means, but each of these spices and herbs have different phytonutrient blends. The magic comes from those phytonutrients. Recall the image of the various sizes of measuring spoons. A teaspoon is 5 grams, a half teaspoon is 2.5 grams, and an eighth of a teaspoon is 0.625 grams. That illustrates how little of a spice you need per serving. Keep that in mind if you decide to spice up your meals.

What we don’t know is whether there’s any interaction between those spices and herbs that would impact the inflammatory hormones. We know that turmeric and ginger have been studied extensively. The researchers recommended testing each spice individually.

Two Observations

There are probably dozens of factors that need to be examined, but two stand out in my mind. First, we’ll need to find out the impact of cooking on each of the different herbs and spices. Does heat destroy the phytonutrients or does it enhance them? We have a partial answer from this study because the spices were put into the dishes as they were being prepared and not added as a topping.

Second, if you take supplements with phytonutrient blends in them, it may be wise to take them either before or while you’re eating so the phytonutrients will be available to help during the digestive process. I’ve always recommended taking your supplements whenever you can remember to take them, and I still stand by that because consistency is more important than timing. But if you can increase the potential benefits by taking them with meals, that’s a good idea.

The Bottom Line

The reason that I loved this approach to research is because it was practical. By that I mean, instead of assessing only one food or a specific group of foods, this study looked at what we would consider “bad foods” together with herbs and spices that are full of phytonutrients to see how they work together.

If you think about it, if saturated fat and refined carbohydrate were as bad as they’re thought to be for the risk of CVD or type 2 diabetes, those diseases would take effect much faster. But perhaps, cake with dark chocolate frosting or French fries with ketchup work with their phytonutrients to somewhat neutralize the bad effect of the food by itself. It doesn’t mean that we don’t bear responsibility; we should still eat as healthy as we can. But perhaps if we choose wisely, we may be able to enjoy some of the food that are perceived as not as healthy if we can spice them just right.

What are you prepared to do today?

        Dr. Chet

Reference: J Nutr 2020;150:1600–1609.

The Health Benefits of Spices

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Continuing our look at the research study on the effect of spices on markers of inflammation, there were some interesting results. The high-fat, high-carbohydrate meal was coconut curry chicken, a cornbread muffin, and a biscuit; that strikes me as an odd meal, but you do what you must for research. The only difference was the spices added to allow for comparative results.

Examining the effect of the 1,000-calorie, high-fat, high-carbohydrate meal, the researchers found an increase in the release of inflammatory hormones above baseline in all subjects. So that’s the first result: inflammation was increased after eating the test meal with no spices added.

Compare that to consumption of the same meal with six grams of spice blend: it significantly reduced IL-1β secretion at four hours after the meal compared with the meal with none of the spice blend. Also, IL-6, IL-8, MCP-1, and TNF-α secretion after the meal containing six grams of the spice blend was below baseline values for each cytokine (inflammatory hormone). These results suggest that spice consumption may reduce inflammation after a high-fat, high-carbohydrate meal for hours after eating. The paper is Open Access, so you can read it yourself at the link in the references.

Those are interesting results, and I’m guessing you really would like to know which spices were used in the study. I’m going to give you that spice blend and put this research in context in Saturday’s memo. But if you haven’t done our little experiment with the teaspoon, half teaspoon, and eighth teaspoon, please do it before then.

What are you prepared to do today?

        Dr. Chet

Reference: J Nutr 2020;150:1600–1609.

Can Spices Make You Healthier?

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I’d like you to do something before you read the rest of this memo. Go to your drawer that contains measuring spoons, and pull out the teaspoon, half teaspoon, and eighth teaspoon. Then measure out salt or sugar for each different volume and put it on a plate. Notice how little there is by the time you get to the eighth teaspoon. Keep that image in your mind for the remainder of the week.

Too often, nutrition research lacks a practical approach; researchers try to drill down into the details before they look at the larger response to any intervention. In other words, examining what people actually eat and cook, then changing something and seeing what happens. I don’t mean exaggerated results such as weight loss, but more subtle effects such as changes in triglycerides, cholesterol, blood sugar, and in this case, markers of inflammation.

This week we’re going to take a look at a recently published paper that took exactly that approach. Researchers selected a group of 12 overweight male subjects with at least one additional risk factor for cardiovascular disease and fed them a high-fat, high-carbohydrate, 1,000-calorie meal. They fed them the same meal on three different days: once without any specific spice blend, second with two grams of a spice blend, and the third time with six grams of the same spice blend. They tested the subjects to see what markers of inflammation were changed after each feeding. I’ll give you the results in Thursday’s memo.

What are you prepared to do today?

        Dr. Chet

Reference: J Nutr 2020;150:1600–1609.

Cost vs. Benefit for Saturated Fat

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In Tuesday’s Memo, I suggested that I don’t like speaking in absolutes when it comes to health recommendations; I’ve seen too many exceptions. What about our Michigan cardiologist? Was he correct? Yes and no, but mostly no.

He implied in the interview that the source of saturated fat is animal products. That isn’t true. In fact, someone could be a vegan and still over-consume saturated fats from using vegetable oils. Palm oil, vegetable oil, even almonds and other nuts that contain monounsaturated and polyunsaturated oils also contain saturated fats. My point is that even without any animal products such as cheese or milk, you can still get a lot of saturated fat in a vegan diet.

He was also overstating the positive effects of lowering saturated fat intake. I read the abstract; it said that it would take 56 people lowering their saturated fat intake for two years to prevent a single cardiac event. Further, the review did not show any reduction in mortality. To me, it raised a lot of questions that may have been answered but not reported.

Should we lower our saturated fat intake? Probably, but it’s going to take a lot more answers to swing the cost to benefit ratio in favor of giving up animal products for the potential benefits we may get.

What are you prepared to do today?

        Dr. Chet

Reference: Cochrane Library. https://doi.org/10.1002/14651858.CD011737.pub2

“Give Up Meat or Else!”

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“Animal Foods Conclusively Cause Heart Disease!” was the title in my news feed that attracted my attention. I had to check it out, because I’m not a fan of absolute statements in the health field; too often, some facts have to be ignored to make definitive statements such as that true. Was this any different?

A cardiologist from Michigan was interviewed in response to a recently published paper in the Cochrane Review. The review updated the information related to saturated fat intake and the rate of cardiovascular disease and mortality. After reading the paper, that’s the response the doctor gave to an interviewer from the Plant Based News. He suggested that the review conclusively shows that reducing saturated fat intake will result in a 21% decrease in CVD events. The implication is that most saturated fat comes from animal products: if we really buckle down and reduce our saturated fat consumption more, we can reduce events even further.

He makes the connection between animal products and saturated fat. But is that correct? It would mean that vegans, who consume no animal products, are protected from cardiovascular disease. Is that true? I’ll let you know on Thursday

What are you prepared to do today?

        Dr. Chet

It’s Official: Prescription Fish Oil

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The U.S. Food and Drug Administration approved the prescription fish oil Vascepa for expanded use on Friday, December 13. The approval for the medication is for the secondary prevention of cardiovascular disease in patients under the following conditions:

  • Triglycerides above 150 mg/dl for everyone with diagnosed CVD and taking a statin medication.
  • Diabetes and two or more additional risk factors for CVD along with taking a statin medication.

The modifiable risk factors for CVD include smoking, obesity, high cholesterol, hypertension, and sedentary living. Remember from our prior series, secondary prevention may help reduce the risk of CVD symptoms developing.

My concerns are the same as they were before. Triglycerides less than 250 mg/dl can be resolved by diet and exercise in most people. Because the mechanism of action is unknown as to how the prescription works, there’s no reason to think that reducing triglycerides by lifestyle change won’t work as well as the prescription; the clinical trial didn’t track this data.

Speaking of lifestyle change, keep in mind the website specials on the Optimal Performance program as we get ready for the New Year. The Basic Meal Plan will teach you how to change your diet to reduce triglyceride levels if your levels are too high.

What are you prepared to do today?

        Dr. Chet

References:
1. http://bit.ly/36EbsYK
2. N Engl J Med 2019;380:11-22. DOI: 10.1056/NEJMoa1812792.