Tag Archive for: mortality

Flavonols: Eat, Drink, and Maybe Live Longer

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The analyses of the NHANES study on flavonols and mortality did more than just look at a class of phytonutrients; researchers also looked at the individual flavonols and how they impacted mortality. A little background first.

Flavonoids

Flavonoids are a group of phytonutrients made up of six classes of nutrients. They are flavan-3-ols, flavones, flavanones, anthocyanidins, and the previously mentioned flavonols. Each of those classes are made up of individual phytonutrients. Flavonols have four primary phytonutrients in its class: quercetin, kaempferol, myricetin, and isorhamnetin. We’ll skip the rest of the individual phytonutrients in the other classes because they weren’t part of the study.

The researchers examined the reduction in mortality for each flavonol phytonutrient. When comparing the first quartile (lowest) with the fourth quartile (highest) intake, not every phytonutrient reduced the mortality from all conditions. In other words, the overall reduction in mortality was greatest when looking at total flavonol intake, not in any single phytonutrient. Too often research focuses on single phytonutrients as potential treatments of conditions and diseases, so it’s great to see a study that looks at total intake of a class of nutrients.

Absorption

As mentioned, flavonols are one part of the flavonoids. One characteristic is that they seem to be poorly absorbed. Or are they? It could be that there are unknown genetic factors that impact absorption and/or utilization of those nutrients. It may be that when isolated from a plant, the absorption is interfered with in some way that’s not apparent. It may be that the microbiome has a role to play in absorption.

What is most likely is that when eaten or drunk in its natural or prepared state, it is the interaction of all the flavonols that help absorption. Or it may be the combinations of flavonoids found in specific foods that work together for absorption.

What foods have the highest flavonol content? When looking at mg/100 grams, raw onions, cooked onions, apples with the peel, brewed black decaf tea, and brewed black tea top the list. When looking at the top three consumed? Onions, black tea, and apples top the list, but beer comes in fourth place. While the amount per 100 grams is low, we consume a lot of it.

The Bottom Line

At the end of the day, the most important thing to know is that we have to consume flavonols to get the benefits. In reality, your mama was right: eat your fruits and vegetables. They’re good for you. And if you chase them down with a beer, that’s probably okay as well.

What are you prepared to do today?

        Dr. Chet

Reference: Nature Reports. 2024. https://doi.org/10.1038/s41598-024-55145-y2. Arch

How Flavonols Affect Mortality

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Observational studies are just what the title indicates: observing something over time. In the case of the National Health and Nutrition Examination Survey (NHANES), one of the objectives is to observe the relationship between diet and whether it impacts how long we live. I recently came across a paper that examined the relationship between flavonol intake and mortality. Observational studies cannot give cause and effect; they can only suggest a relationship, which would then be followed up with randomized controlled trials. That doesn’t happen often enough in nutrition studies; how do you blind subjects to the foods they’re eating? Therefore, we take what we can get.

Researchers wanted to find out the relationship between one class of flavonoids called flavonols and mortality. They used data from the volunteers in three different NHANES data collection periods who completed a 24-hour dietary recall with an in-person interview and telephone follow-up. This is about as good as it gets when collecting dietary data in such large studies—over 11,000 subjects.

After accounting for age, gender, and other factors, there was a clear relationship between flavonol intake and mortality. Total flavonol intake was associated with an overall decrease in all-cause, cancer-specific, and CVD-specific mortality risks. The decrease in hazard ratio was as much as cutting the risk in half (cancer-specific) and by one-third from CVD and all-cause mortality; results were not as clear for diabetes and Alzheimer’s disease. There’s more to this study, and I’ll cover it on Saturday including the foods with the highest flavonol levels.

What are you prepared to do today?

        Dr. Chet

Reference: Nature Reports. 2024. https://doi.org/10.1038/s41598-024-55145-y2. Arch

Less Can Be More If…

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Let’s dig into the results of the National Health Interview Survey analysis to see if less really can be more: does mortality decrease even with fewer than 30 minutes per day most days of the week as long as part of the workouts was vigorous? We’re not examining other potential health benefits of exercise such as the risk of type 2 diabetes, weight loss, or gaining strength—just risk of death.

I examined the Hazard Ratios for the number of minutes spent in vigorous physical exercise per week and the total minutes of exercise per week. For those who exercised 1 to 149 minutes per week (less than the national recommendations), if 1 to 74 minutes of the total were spent in vigorous exercise, there was a 29% decrease in all-cause mortality. For CVD, there was a 20% decrease in mortality and a 24% decrease in mortality from cancer. There were additional benefits when a greater number of minutes were spent in vigorous activity, especially from CVD. Clearly, less can be more.

But…

A person must be fit enough to be able to do vigorous exercise. The survey defined vigorous exercise as hard enough to raise the heartrate and breathing rate and to increase sweating. The older you are, the less you may be able to sustain that type of effort, whether due to a lack of fitness or pre-existing CVD or orthopedic issues; the same holds true for someone who is overweight or obese. If you’re in any of those categories, you must get your physician’s approval before doing intense exercise.

You don’t have to wait, though; work up to it over a period of months with the guidance of a professional exercise specialist. Just as with any goal, you approach it in a stepwise manner. If you can walk for exercise, it may be something as simple as walking fast for 15 seconds every 3 minutes. Progress from there, increasing the fast walking by 15 seconds every week or every few days. If your body isn’t ready yet, it will let you know.

If you can get 20 to 30 minutes most days with over half of those minutes being vigorous, you may reap the benefit of lower risk of death, according to the data. Just proceed with caution and remember, this doesn’t include time working on strength, endurance, or flexibility.

What are you prepared to do today?

        Dr. Chet

References: JAMA Int Med. doi:10.1001/jamainternmed.2020.6331

Exercise: It All Counts

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Here’s something to ponder the rest of the week: why do you exercise? If you don’t, what would your purpose be if you did? I think there are two primary reasons. First, burning calories helps lose weight. Second, if you exercise regularly, you might live longer. But then you hit those exercise recommendations: 150 minutes per week—30 minutes a day five days a week. Who has that much continuous time? Maybe it doesn’t have to be continuous.

A recent published study used data from the NHANES database to determine whether exercise had to be continuous or whether it could be done in shorter segments they called bouts in order to have benefit. They looked at a single outcome: mortality. The subjects wore accelerometers to determine activity levels throughout the day. It turns out that whether you do your 30 minutes of exercise continuously or break the 30 minutes into bouts or segments lasting at least five minutes at a time, there was no difference in the reduction in mortality. Of course, the more total minutes per week were associated with continuing decreases in mortality, but it didn’t matter whether it was in shorter bursts or continuous minutes.

If you want to exercise to live longer, just get moving at least five minutes at a time several times per day. Whether bouted exercise will get you fitter is a different question, but if you want to live longer, get moving.

I know you’ll be busy buying chocolate this weekend no matter what your religious affiliation, so no memo on Saturday. I’ll be back next Tuesday.

What are you prepared to do today?

Dr. Chet

 

Reference: J Am Heart Assoc. 2018;7:e007678. DOI: 10.1161/JAHA.117.007678.

 

The Truth Behind the Obesity Paradox

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In my opinion, the short answer to the obesity paradox is that it doesn’t really exist. But what fun would that be? That doesn’t teach you anything. Let’s take a look at the problems with the research that contributed to this paradox.
 

Study One: Dialysis, BMI, and Mortality

A study of dialysis patients led to the first observation that people with higher BMIs lived longer (1). After tracking over 1,300 subjects on dialysis for a year, researchers found that those who were overweight had a decreased risk of dying and had fewer hospital stays when compared to those who were underweight. This may have been the study that yielded the name The Obesity Paradox. The problem? The study lasted only one year. Trying to generalize what will happen to all overweight and obese people on dialysis from a study that lasted only one year and at only a single location isn’t realistic. It raises an intriguing question, but we’ll need a much more extensive study to really make a solid prediction.
 

Study Two: The Rotterdam Study

I described this study on Thursday (2). While the study appeared to show a protective benefit from being overweight or obese, the subjects were elderly with an average age of 77 at the study’s beginning. One risk factor that you cannot change is age: the older you are, the more likely you are to die. But that’s not the whole story. We can probably say that older people may live longer with a little extra weight, but to extend that prediction to all age groups isn’t valid.
 

Study Three: BMI and Mortality

While this study claimed to analyze the data on over two million people, it was still a meta-analysis (3), which doesn’t yield cause and effect, just a statistical association. Further, they used studies of varying lengths without necessarily knowing exact causes of deaths. They also did not have precise BMIs on everyone; some studies included metrics such as BMI under 27.5 and over 27.5. They tried to include the highest number of subjects, but the quality of data varied and that made it a mess. Researchers chose too many different types of studies in the meta-analysis, and it just doesn’t work. I wouldn’t bet my life on it.
 

Study Four: A Broader Look

The real problem with every approach is the lack of acknowledgement that people with advanced disease may have lost weight before they were included in the study; diseases such as heart failure, diabetes, or renal disease will often lead to weight loss. Those who were heavier when disease hit had the benefit of extra energy stored as fat to deal with the disease, and that could explain the outcomes of those studies. It had nothing to do with being obese; it was a matter of timing.

A study published last month appears to confirm that (4). Researchers in the Cardiovascular Disease Lifetime Risk Pooling Project obtained data from 10 different longitudinal studies, including individual-level data and accurate mortality data. They found that as BMI increased, the death rate from all forms of CVD increased. For those who carried extra weight while younger, CVD occurred earlier, making it more likely they would die before their time.
 

The Bottom Line

As I said, there really is no obesity paradox. Being overweight or obese carries with it risks of degenerative disease. Some people may have better genes and may gain protection for a few years. But in the end, being overweight or obese carries a higher risk of various diseases than the limited protection from an advanced disease you may gain by carrying extra weight. So my advice is the same as it always was: if you’re overweight, your best bet for a long, healthy life is to lose it.

What are you prepared to do today?

Dr. Chet

 

References:
1. Kidney International, Vol. 55 (1999), pp. 1560–1567.
2. European Heart Journal (2001) 22, 1318–1327.
3. JAMA. 2013; 309(1): 71–82.
4. JAMA Cardiol. doi:10.1001/jamacardio.2018.0022.

 

Does a Little Extra Weight Keep You Alive?

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The Rotterdam Study was begun in 1991 to investigate the risk factors of cardiovascular, neurological, ophthalmological, and endocrine diseases in people 55 and older (1). The study is still ongoing, but periodically subsets of subjects are examined to find out which characteristics are associated with these diseases. In a study published in 2001, researchers reported on a group of subjects who were diagnosed with heart failure at the beginning of the study and followed for an average of six years—181 out of over 5,000 subjects. By the end of five years, 85 subjects had died. One of the observations that researchers noted was that a higher BMI was associated with reduced mortality; in plain terms, the heavier people were more likely to stay alive.

It didn’t stop there. In 2013, a study was published that directly examined the relationship between BMI and mortality (2). This meta-analysis included 97 studies and examined more than 2.88 million participants and more than 270,000 deaths. They reported that while grades 2 and 3 obesity (grade 2: BMI of 35-39.9; grade 3: BMI more than 40) were associated with increased mortality, grade 1 (BMI of 30-34.9) was not, and the overweight category (BMI of 25-29.9) actually showed a reduced risk of dying. (How do you rate? Check your BMI here.)

Is this true? Is body weight not associated with an increased risk of death? Have we been trying to lose weight for no reason? I’ll finish this on Saturday.

What are you prepared to do today?

Dr. Chet

 

References:
1. European Heart Journal (2001) 22, 1318–1327.
2. JAMA. 2013 January 2; 309(1): 71–82.

 

What Is the Obesity Paradox?

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Did you ever hear something that didn’t seem to make sense? That seemed to go against everything you thought to be true? One example of this is something called “The Obesity Paradox.” I’ve seen a few headlines this week that have talked about it, so it’s time to address it in the Memo.

One of the variables that we would think is related to the development of cardiovascular disease would be body weight. It seems logical: as weight increases, so does the strain on pumping the blood through the additional blood vessels required to feed the extra fat and muscle. People who are overweight may eat the wrong foods, consume too much food, and move too little.

But since the early 2000s, several studies have been published seeming to show that body weight wasn’t necessarily a risk factor for CVD or an early death. They showed that those who were overweight, a BMI between 25.0 and 29.9, had lower mortality rates than those who were normal weight. Some showed that stage-one obesity, a BMI between 30.0 and 34.9, was also not related to mortality. Thus the term “The Obesity Paradox” was coined. But is it true? We’ll take a look at the research the rest of the week.

What are you prepared to do today?

Dr. Chet

 

The Bottom Line on Veggies and Carbs

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Go ahead and finish your oatmeal and drink your protein-kale smoothie—you do need those veggies. Meanwhile I’ll put the PURE study in perspective.

This is a large study that looks at the economics of food as well as the health benefits. In a separate publication, the analysis of the data focused on the cost of fruit and vegetable intake as a percentage of monthly income. They specifically collected data from low-, middle-, and high-income communities from 18 different countries. Researchers actually went to grocery markets in those countries to collect the cost data. As you might expect, the lower the income, the higher the percentage of monthly revenue spent on vegetables and fruits.

I think that explains part of the reason the second study on vegetable intake and mortality said there was no additional benefit beyond three or four servings per day: if people can’t afford more, it’s wrong to teach them that more is better if it might not be. But that doesn’t justify the headlines because the message that Americans hear is “I don’t have to eat those darn vegetables!”

Yes, you do. Here are the issues with each of the studies.

 

Do Carbs Kill?

In the first study on carbohydrate intake and mortality, researchers used a simple percentage of caloric intake in their analysis. Basically we have a math problem: if someone in a poor country eats 80% of their diet as carbohydrates from root vegetables but they only get 1,000 calories per day that’s a completely different situation from a person who eats 3,000 calories per day but 50% of their calories are from refined carbohydrates and sugars.

As I’ve said many times, while we should eat fewer refined carbohydrates, carbohydrates are not inherently bad; it is the overconsumption that’s the problem. If researchers didn’t analyze the total caloric intake from carbohydrates, protein, and fats, we don’t have the complete answer. The PURE study used a food frequency questionnaire. I’ll leave it at that because I rant too much about the FFQs.

Finally, the researchers simply jumped the gun by recommending that health education should now focus on increasing fat intake while reducing carbohydrates. All types of vegetables and fruits are carbohydrates. Because researchers did not parse out different sources of carbohydrates in their analysis, their recommendations are meaningless.

 

Don’t Bother with More Veggies?

PURE is an observational study; it cannot determine cause and effect. Also it can tell you a lot about a large group of people but nothing about an individual.

The lead researcher actually provided the perspective on vegetables and fruit during an interview: if the research shows that the benefit of eating more plant-based food is a 20% reduction in mortality, and the mortality rate of the population is just 1%, that means the reduction goes from 10 out of 1,000 to 8 out of 1,000. It’s virtually meaningless to an individual.

The researchers hesitated to tell people with very low incomes to spend more on additional servings of plant-based food if there was not a meaningful benefit. But for most of you, the cost of fruit and vegetables is not a hardship, so buy ’em and eat ’em.

 

The Bottom Line

These will not be the last headlines we hear from the PURE study because the data continues to be analyzed. One issue for me is that there’s no data from the U.S. included so the ability to generalize to the U.S. population is very limited. We lead the world in obesity and overweight and our food consumption patterns are different even from other Westernized countries.

One thing remains clear to me: we should all eat more vegetables and fruit and reduce refined carbohydrates. The recommendation never changes: eat less, eat better, move more.

What are you prepared to do today?

Dr. Chet

Reminder to Insiders: The next Insider Conference Call will be Tuesday at 9 p.m. Not an Insider? Join now to participate in this call and get your questions answered.

 

References:
1. DOI: http://dx.doi.org/10.1016/S0140-6736(17)32252-3.
2. DOI: http://dx.doi.org/10.1016/S2213-8587(17)30283-8.

 

PURE Headline 2: Don’t Bother with More Veggies?

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Using the same data base of subjects in the PURE Study, researchers examined the vegetable, fruit, and legume intake on total mortality, mortality, and major cardiac events such as heart attacks.

The most important finding was that higher vegetable, fruit, and legume intake was associated with a reduced risk of mortality and morbidity. Simply put, the more plant-based the diet, the better off you are from an overall health perspective.

But that’s not what the headline messages said. They focused on the part of the study that said there appeared to be no additional benefits if subjects ate more than a few servings of vegetables, fruits, and legumes. That seems to fly in the face of the “more is better” results that previous research has shown.

Have all the prior studies been wrong? Have you been eating kale for no good reason? No, and I’ll explain why the headlines are wrong on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: DOI: http://dx.doi.org/10.1016/S0140-6736(17)32253-5.

 

PURE Headline 1: Do Carbs Kill?

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Never a dull moment when it comes to health news: now they’re asking if you should choose fat rather than carbs.

The research study was called PURE: Prospective Urban Rural Epidemiology, and you’ll be hearing more about it. Over 150,000 people from five continents, 18 countries, and 613 different communities were included in the study. Researchers collected data on demographics, smoking habits, and health questionnaires including a semi-quantitative food frequency questionnaire (FFQ).

In the first paper, researchers examined the relationship between macronutrient intake, specifically fats and carbohydrates, and total mortality including cardiovascular events. Higher fat intake was associated with a decreased risk of total mortality while high carbohydrate intake was associated with a higher risk of mortality. There was no specific relationship between either macronutrient and heart disease.

Should you put down that rice? How about the bread? What about that cabbage and broccoli? Before you decide, let’s check out the second headline grabber on Thursday.

What are you prepared to do today?

Dr. Chet

Insider Update: The next Conference Call will be next Tuesday September 25 at 9 p.m. If you’re not an Insider yet, join now to participate in this information-packed call and get your questions answered.

 

Reference: DOI: http://dx.doi.org/10.1016/S2213-8587(17)30283-8