Could this be related to excessive consumption of egg nog?
Egg nog is composed of eggs, cream, milk and booze. All of these ingredients have become associated with increased risk of heart disease in the mind of the public.
Nutritional guidelines advise us to limit egg consumption, especially the yolk, and use low-fat dairy to reduce our risk of heart disease
A close look at the science, however, suggests that egg nog may actually lower your risk of heart disease.
Eggs are high in cholesterol but as I’ve discussed in a previous post, cholesterol in the diet is not a major determinant of cholesterol in the blood and eggs have not been shown to increase heart disease risk.
Full fat dairy contains saturated fat, the fat that nutritional guidelines tell us increases bad cholesterol in the blood and increases risk of heart attacks. But some saturated fats improve your cholesterol profile and organic (grass-fed, see my previous post) milk contains significant amounts of omega-3 fatty acids which are felt to be protective from heart disease.
Milk and dairy products are associated with a lower risk of vascular disease!
Whether you mix rum, brandy, or whisky into your egg nog or you drink a glass of wine on the side you are probably lowering your chances of a heart attack compared to your abstemious relatives. Moderate alcohol consumption of any kind is associated with a lower risk of dying from cardiovascular disease compared to no alcohol consumption.
So, drink your egg nog without guilt this Holiday Season!
You’re actually engaging in heart healthy behavior.
The skeptical cardiologist has to admit that when he drinks milk or puts it in his coffee or cooks with it he almost exclusively drinks “organic”, non-homogenized milk obtained from dairy cows which are grass-fed and spend most of their lives grazing in a pasture.. In previous blogs I’ve laid out the evidence that supports that dairy products in general do not increase the risk of heart and vascular disease and, in fact, may lower that risk.
Full fat dairy has gotten a bad rap because it contains high levels of saturated fat. However, just as total fats were inappropriately labeled as bad , it is now clear that all saturated fats are not bad for the heart.
Although I recommend full fat dairy products to my patients I haven’t emphasized the organic or grass-fed aspect because I didn’t think there was enough good evidence that this is healthier than other kinds of milk and it is more expensive. There is evidence from small studies that cows consuming a more natural diet of grass and legumes from a pasture have higher levels of omega-3 fatty acids in their milk than those confined indoors and eating corn.
I keep my eyes (and ears) open for papers in this area.. One such paper appeared in the online peer-reviewed publication PLOS recently. I was driving to the hospital, listening to NPR when I first heard about it. Melissa Block was interviewing NPR correspondent Allison Aubrey . Her take, in a more subdued written form here is similar to many news outlets.
Allison summarized the findings as follows
The researchers compared organic and conventional milk head-to-head. They analyzed about 400 samples over an 18-month period, to account for seasonal differences. And the samples were taken from, you know, all different parts of the country. And they found that organic milk had about 62 percent more of the heart healthy omega-3s, compared to conventional milk.
When asked for an explanation she said
It really comes down to watch what the cows were eating. Organic milk is produced from cows that spend a lot more time out on pasture, and they’re munching on grasses and legumes. And these greens are rich in omega-3 fatty acids. So as a result, the milk they produce has more omega-3 fatty acids.
Wait a minute! I said , you’re confusing “organic” and “grass-fed” or “pasture raised ” they are two totally different things although they can overlap. I totally get the concept of a healthier diet for the cows increasing omega-3s in their milk but I haven’t seen anything that would suggest reducing pesticide or antibiotic usage does that. The radio did not respond. Also, I asked, is it possible to use the term omega-3 without prefacing it with “heart healthy”?
Once you start demanding to know more about the conditions of the cows that made the milk you drink things can become complicated. A cow can be grass-fed but not pasture raised, meaning that it stayed indoors and was fed hay. A cow can be outside “grazing ” but be given corn to eat. Prior to looking at the PLOS one article, I did not assume organic implied anything about how the cows were fed or grazed.
It turns out that in 2010 the USDA announced guidelines that mandated, among other things, for a dairy to be called “organic”, its dairy cows had to spend at least 120 days grazing on pasture.Thus, there is some correlation between organic and pasture raised/grass-fed but not a complete one.
The PLOS one study looked at geographical variation in the difference between organic and conventional milk fatty acid content. Northern California was the only region in which there was no significant difference. The authors speculated that this was because conventional farmers in Norther California usually have cows that roam on the pasture and eat grass and legumes. Thus, it appears the differences between organic and conventional milk are primarily due to what the cows were eating rather than the presence or absence of pesticides, antibiotics, GMOs, or hormones.
Allison Aubrey went on to say
But you know, I should say that there’s a trade-off here because in order to get all these extra omega-3s, you’ve got to drink whole milk. And you know, if you opt for the low-fat dairy – say, 1 percent fat -you’ve skimmed off most of these omega-3s. So the question is, you know, can you afford the extra calories in fat. If you choose the whole milk, you might need to trim a few calories from elsewhere in your diet.
To which I responded “Yes, by all means drink whole milk, there is no evidence that it adds to obesity. You will naturally want less calories down the line and you will get the benefit of good saturated fats.”
I'll continue to pay extra to drink milk from Trader's Point Creamery that I pick up at Whole Foods. I like their milk because I've visited their farm in Indiana and talked to their (plastic surgeon) owner and I like what he says on the website about their milk (ignoring the part about a “better immune system”.
We let our cows graze on 140 acres of pesticide free pasture, which results in milk with more healthy fats like Omega 3 and CLA (conjugated linoleic acid). Grassfed milk also contains more nutrients like beta carotene and vitamins A and E than milk produced using standard feeds. To all of us this means more nourishment and a better immune system for our bodies.
I’m going to end with the summary from the PLOS one article (DMI=dry matter intake, LA=linolenic acid, an omega-6 fatty acid) which emphasizes the importance of grazing and forage-based feeds not the organic aspects of milk.
We conclude that increasing reliance on pasture and forage-based feeds on dairy farms has considerable potential to improve the FA profile of milk and dairy products. Although both conventional and organic dairies can benefit from grazing and forage-based feeds, it is far more common—and indeed mandatory on certified organic farms in the U.S.—for pasture and forage-based feeds to account for a significant share of a cow’s daily DMI. Moreover, improvements in the nutritional quality of milk and dairy products should improve long-term health status and outcomes, especially for pregnant women, infants, children, and those with elevated CVD risk. The expected benefits are greatest for those who simultaneously avoid foods with relatively high levels of LA, increase intakes of fat-containing dairy products, and switch to predominantly organic dairy products.
It always irritates me when a friend tells me that I should eat breakfast because it is “the most important meal of the day”. Many in the nutritional mainstream have propagated this concept along with the idea that skipping breakfast contributes to obesity. The mechanism proposed seems to be that when you skip breakfast you end up over eating later in the day because you are hungrier.
The skeptical cardiologist is puzzled. Why would i eat breakfast if I am not hungry in order to lose weight? What constitutes breakfast? Is it the first meal you eat after sleeping? If so, wouldn’t any meal eaten after sleeping qualify even it is eaten in the afternoon? Is eating a donut first thing in the morning really healthier than eating nothing? Why would your first meal be more important than the last? isn’t it the content of what we eat that is important more than the timing?
eat a nutrient-dense breakfast. Not eating breakfast has been associated with excess body weight, especially among children and adolescents. Consuming breakfast also has been associated with weight loss and weight loss maintenance, as well as improved nutrient intake
Eating a healthy breakfast is a good way to start the day and may be important in achieving and maintaining a healthy weight
A recent study anayzes the data in support of the “proposed effect of breakfast on obesity” (PEBO) and found them lacking.
This is a fascinating paper that analyzes how scientific studies which are inconclusive can be subsequently distorted or spun by biased researchers to support their positions. It has relevance to how we should view all observational studies.
Observational studies abound in the world of nutritional research. The early studies by Ancel Keys establishing a relationship between fat consumption and heart disease are a classic example. These studies cannot establish causality. For example, we know that countries that consume large amounts of chocolate per capita have large numbers of Nobel Prize winners per capitaChocolate Consumption and Nobel Laureates
Common sense tells us that it is not the chocolate consumption causing the Nobel prizes or vice versa but likely some other factor or factors that is not measured.
Most of the studies on PEBO are observational studies and the few, small prospective randomized studies don’t clearly support the hypothesis.
Could the emphasis on eating breakfast come from the “breakfast food industry”?
I’m sure General Mills and Kellogg’s would sell a lot less of their highly-processed, sugar-laden breakfast cereals if people didn’t think that breakfast was the most important meal of the day.
My advice to overweight or obese patients:
Eat when you’re hungry. Skip breakfast if you want.
If you want to eat breakfast, feel free to eat eggs or full-fat dairy (including butter)
These foods are nutrient-dense and do not increase your risk of heart disease, even if you have high cholesterol.
You will be less hungry and can eat less throughout the day than if you were eating sugar-laden, highly processed food-like substances.
As I pointed out in an earlier blog , individual vitamins and multivitamins have been proven over and over to have no benefit for heart disease.
A recent series of articles in the Annals of Internal Medicine summarized in this accompanying editorial, confirms this and further shows that multivitamins have no benefit on preventing cognitive decline with aging.
The U.S. Preventive Services Task Force reviewed all studies on multivitamins, single and paired vitamins and concluded that there was no benefit of taking these on overall mortality, cardiovascular mortality or cancer.
Hopefully this series of articles will start the decline of the multibillion dollar Vitamins and Supplement industry in the U.S.
For my patients, I recommend a healthy diet that includes, fruits, vegetables, and fish which will provide all the micronutrients and vitamins they need. There is no evidence that you can substitute taking industry-processed micronutrients or fish-oil and expect the benefits to be the same
The Skeptical Cardiologist is a big fan of yogurt. I prefer yogurt in its unadulterated state, 3.5 to 5% milk fat, no sugars added at the factory. Preferably sourced from a local dairy where the cows range freely and eat grass. In this form, yogurt is a very healthy, nutrition-dense, vitamin- enriched food that supplies calcium, essential vitamins, protein and fats.
Yogurt, like all full fat dairy products (with the possible exception of butter) does not increase the risk of heart disease. In fact, some epidemiologic studies show that yogurt consumption is associated with lower risk of heart attacks. It is also associated with less weight gain over time .Because these observational studies can never prove causation we cannot conclude that eating yogurt will reduce our risk of cardiovascular disease or help us lose weight, but certainly there is nothing to suggest that it contributes to heart disease or obesity.
The Frozen Yogurt Scam: Substitute Sugar and Chemicals for Dairy Fat
Yogurt has a reputation as being a “healthy snack.” Sales of yogurt are increasing rapidly with Greek and frozen yogurt, in particular, showing spectacular growth.
Unfortunately, a great hoax has been perpetrated on the American public. Following advice generated from organizations like the American Heart Association and the USDA government nutritional guidelines, with the idea that they are making healthier choices, Americans are choosing yogurt that is nonfat or low-fat.
When the fat is taken out of yogurt, almost invariably sugar in one form or another is added in by the food industry to enhance flavor and make it palatable.
The Healthiest Froyo Orders at Pinkberry, Baskin Robbins, and More Get your frozen yogurt fix without downing an entire mealʼs worth of calories
The teaser line read as follows:
Frozen yogurt may offer a healthier alternative to ice cream, but it can be easy to fall into a calorie trap when you load up on rich flavors and toppings. Check out our cheat sheet to see which froyo combos to order at popular chains. Each one is low in fat and calories—so you can enjoy a guilt-free summer treat!
The number one recommendation was for a sugar and carbohydrate bonanza with the title: “Pinkberry’s Strawberry Classic,” which contains the followingnutritional ingredients:
Nonfat milk, sugar, strawberry flavor (strawberries, sugar, water, natural flavors, fruit and vegetable juice [for color], guar gum, sodium citrate), nonfat yogurt (pasteurized nonfat milk, live and active cultures), nonfat yogurt powder (nonfat milk, culture), fructose, dextrose, natural flavors, citric acid, guar gum, maltodex- trin, mono- and diglycerides, rice starch
Sugar is listed twice and overall there are 23 ingredients that have been added to make this pale imitation of real yogurt palatable. Ironically, Pinkberry claims to have “real” yogurt but the only thing I could tell from their website is the following:
Pinkberry is made with REAL nonfat milk, not from cows treated with rBST hormones, and REAL nonfat yogurt, among many other natural ingredients.
The Shape magazine article recommends you add real strawberries plus a “balsamic glaze” and estimates the total calories as 165 with 144 of which are provided by sugar (36g).
The Skeptical Cardiologist does not recommend this as a “healthy snack” because of the massive amount of sugar, unrefined carbohydrates, and added chemicals. Michael Pollan’s Food Rules are violated multiple times with this ultraprocessed concoction including “Avoid foods with more than 5 ingredients” and” avoid foods which have some form of sugar (or sweetener) listed among the top 3 ingredients”.
Eat Real Food Not Ultraprocessed Industrial Concoctions
In contrast to the typical nonfat frozen yogurt sugar nightmare, a 5 oz serving of whole milk yogurt from Traders Point Creamery has 90 calories total, 5 grams of fat, 7 total grams of carbohydrate and 5 grams of protein.
There are four ingredients listed on the glass bottle for Traders Point Creamery whole milk yogurt: organic whole milk, organic skim milk, live cultures, and probiotic cultures. The cows are also pastured raised and grass-fed.
This is a yogurt I can recommend.
The food industry routinely presents us with ultra-processed, “food-like” substances that are promoted as more healthy but contain added sugar and refined carbohydrates to enhance taste and promote excess consumption. When we consume sugar added by food processing, we are consuming calories without any nutritional value.
There is no science that tells us that substituting sugar for dairy fat is better for you or for your heart. Several lines of evidence suggest excess consumption of sugar and refined carbohydrates contribute to obesity, inflammation and may increase cardiovascular and chronic disease risk. The high glycemic index and resulting spike in blood sugar may trigger hormonal responses that increase inflammation and fat storage.
America’s obesity epidemic seems to have developed as Americans, following dietary guidelines not based in science, began seeking out low-fat substitutes for real foods. Thus, we have witnessed the explosion of fat-free or low-fat frozen yogurt as food marketers and the obliging “health” media trumpeted the health benefits of these products with no evidence to support the claims.
Being the skeptical cardiologist I have to point out that there has been a shameless, unsubstantiated over-hype of the benefits of yogurt in all sorts of areas including immunity, “digestive health,” bladder cancer, and eczema. I’ll review the health benefits (if any) of the “probiotic” or “prebiotic” features of yogurt and the growth of Greek yogurt in future posts.
Full Disclosure: I have no connections with and receive no support from any food industry sponsored organization. I’m not selling anything. I’m just an unbiased cardiologist seeking the truth so I can make evidence-based recommendations on diet to my patients. I do eat Traders Point Creamery yogurt and drink their milk but have no other connection to the whole organic yogurt I featured in the pictures. I have, however, visited their farm and can attest to the fact that the cows are grazing in a pasture and are well treated.
I think eggs are wonderful. They are little balls of nutrition that can be prepared in numerous fascinating ways to make breakfast interesting and delicious. I particularly like omelets. Alas, when I was training as a medical student the medical establishment had embraced the diet-heart hypothesis. It was felt that dietary cholesterol and fat (subsequently modified to saturated fat) by increasing levels of cholesterol in the blood (subsequently modified to raising levels of bad or LDL cholesterol) were responsible for the increasing rate of coronary heart disease that was being observed.
This certainly made sense at the time: If you eat too much cholesterol, of course it’s going to raise your blood cholesterol levels and contribute to the buildup of those nasty cholesterol plaques that would clog your arteries and give you heart attacks and strokes.
Since egg yolks contain 210 mg of cholesterol on average (more recent data suggest they only contain 184 mg/egg), eggs became a target of the dietary police.
The American Heart Association (AHA, the same organization that until recently endorsed sugar-laden cereals like Cocoa Puffs as “heart healthy”) had decided decades ago to recommend restricting egg consumption. In 2010, AHA guidelines restricted everybody’s total cholesterol to <300 mg per day on the flimsiest of evidence. From the AHA guidelines:
“Although there is no precise basis for selecting a target level for dietary cholesterol intake for all individuals, the AHA recommends <300 mg/d on average. By limiting cholesterol intake from foods with a high content of animal fats, individuals can also meet the dietary guidelines for saturated fat intake. This target can be readily achieved, even with periodic consumption of eggs and shellfish. As is the case with saturated fat intake, reduction in cholesterol intake to much lower levels (<200 mg/d, requiring restriction of all dietary sources of cholesterol) is advised for individuals with elevated LDL cholesterol levels, diabetes, and/or cardiovascular disease.”
The official US dietary guidelines on the topic of dietary cholesterol read as follows
“the body uses cholesterol for physiological and structural functions, but it makes more than enough for these purposes. Therefore, people do not need to eat sources of dietary cholesterol. Cholesterol is found only in animal foods. The major sources of cholesterol in the American diet include eggs and egg mixed dishes (25% of total cholesterol intake), chicken and chicken mixed dishes (12%), beef and beef mixed dishes (6%), and all types of beef burgers (5%). Cholesterol intake can be reduced by limiting the consumption of the specific foods that are high in cholesterol. Many of these major sources include foods that can be purchased or prepared in ways that limit the intake of cholesterol (e.g., using egg substitutes). Cholesterol intake by men averages about 350 mg per day, which exceeds the recommended level of less than 300 mg per day. Average cholesterol intake by women is 240 mg per day.
Dietary cholesterol has been shown to raise blood LDL cholesterol levels in some individuals. However, this effect is reduced when saturated fatty acid intake is low, and the potential negative effects of dietary cho- lesterol are relatively small compared to those of saturated and trans fatty acids. Moderate evidence shows a relationship between higher intake of cholesterol and higher risk of cardiovascular disease. Independent of other dietary factors, evidence suggests that one egg (i.e., egg yolk) per day does not result in increased blood cholesterol levels, nor does it increase the risk of cardiovascular disease in healthy people. Consuming less than 300 mg per day of cholesterol can help maintain normal blood cholesterol levels. Consuming less than 200 mg per day can further help individuals at high risk of cardiovascular disease.”
Americans were being told to severely restrict their egg consumption, especially if they had high cholesterol levels, diabetes, or heart disease. Even one egg a day seemed too much. As a cardiologist in training I dutifully took these recommendations to heart. I can’t tell you how many egg beater or egg white omelets I cooked over the next 25 years.
As more evidence accumulated, however, the bulk of the scientific evidence was coming down clearly on the side of eggs and the lack of effect of dietary cholesterol on blood cholesterol levels. As The Skeptical Cardiologist I began embracing the heresy of eating eggs, yolk and all, about two years ago.
Several large epidemiological studies have examined the association of egg consumption and serum cholesterol. The Framingham Heart Study examined the serum cholesterol in high versus low egg consumption and found no significant difference in either men or women. The association between self-reported dietary intake of eggs and serum cholesterol was examined in a population of 12,000 men in the Multiple Risk Factor Intervention Trial. Paradoxically, the men who consumed more eggs had lower serum cholesterol than those who consumed fewer eggs.In the Third National Health and Nutrition Examination Survey (NHANES III), the diets of 20,000 participants were evaluated.
“Compared to egg consumers, nonconsumers had higher rates of inadequate intake (defined by Estimated Average Requirements (EAR) or < 70% Recommended Dietary Allowance (RDA)) for vitamin B12 (10% vs. 21%), vitamin A (16% vs. 21%), vitamin E (14% vs. 22%) and vitamin C (15% vs. 20%). After adjusting for demographic (age, gender and ethnicity) and lifestyle variables (smoking and physical activity), dietary cholesterol was not related to serum cholesterol concentration. People who reported eating > or = 4 eggs/wk had a significantly lower mean serum cholesterol concentration than those who reported eating < or = 1 egg/wk (193 mg/dL vs. 197 mg/dL, p < 0.01”
Study after study in the next 20 years showed that egg consumption was not associated with coronary heart disease and strokes. A more recent study from Spain shows no association of egg consumption on cardiovascular disease. A meta-analysis of all prospective cohort studies published in 2013 concluded that there was no association between higher egg consumption and coronary heart disease or stroke. Studies (randomized controlled trials) that actually prove that egg consumption causes cardiovascular disease are totally lacking. Nutritional guidelines should have concluded that there was no reason to restrict egg consumption in the vast majority of Americans.
Unfortunately, the AHA guidelines (and mainstream nutritional advisors) to this day continue to embrace the 300 mg/ day limit on cholesterol (although most other countries have dropped it). Most of my patients, having heard that eggs are bad for the heart, mistakenly try to restrict the amount they eat or eat egg whites. I see my fellow doctors in the doctors’ lounge taking boiled eggs out of the refrigerator, scooping the yolk out and eating only the egg white.
Why doesn’t more cholesterol in the diet lead to higher blood cholesterol level and subsequently to heart attacks? The answer is complicated, beyond the scope of this blog, but it illustrates how amazingly complex the body’s regulation of lipids and lipoproteins is, as well as how complicated the process of atherosclerosis is.
There are at a very basic level 3 main types of fat that doctors measure in the blood to help us gauge heart disease risk: the low density lipoprotein (LDL) cholesterol portion or “bad”, the high-density lipoprotein (HDL) cholesterol or “good,” and the triglycerides (esterified fatty acids). On a very simplistic level, we tell patients that higher LDL levels tend to build up fatty plaques, whereas higher HDL levels can be thought of as reducing fatty plaques. When we eat an egg there is a complex reaction to the fats, proteins, sugar, and cholesterol absorbed into the blood stream. Although the LDL rises (which might increase coronary artery disease (CAD) risk), the HDL also rises (which might lower CAD risk) and there is a variable response of triglycerides. To further complicate things, each of the cholesterol fractions has good forms and bad forms. LDL can be in a large, “fluffy” state that is not prone to promoting plaque formation or a small, dense form that does promote plaque formation. Eggs seem to promote the less atherogenic forms of both LDL and HDL. In addition, inflammation plays an important role in the process of atherosclerosis. Certain components of egg yolks may actually reduce inflammation, making plaque formation less likely.
Certain components of eggs may be beneficial and outweigh any theoretical concern about cholesterol consumption.. Eggs are the major sources of lutein and zeaxanthin, two potent anti-oxidants, which in addition to their recognized protective effects against macular degeneration and cataract formation, may also reduce LDL oxidation.
Eggs also contain choline, a nutrient that is needed for membrane formation, methylation and acetylcholine biosynthesis, which plays a major role in normal fetal development. Some studies suggest a role of choline in protecting against Alzheimer’s disease
Eating eggs may contribute to weight loss compared to eating carbohydrates. A recent study compared two different breakfasts, a bagel-based and an egg-based breakfast. During the egg period, men had a significantly lower caloric intake not only in the next meal, but also in the following 24 hours.
To make things more complicated, all eggs are not created equal. Hens that are allowed to range freely on a farm and eat grass, bugs and what might be considered their normal diet, have a different amount of omega-3 fatty acids than those that are fed grain. Given America’s current obsession with fish oil supplements (see my prior post), this makes these eggs perceived as healthier. By manipulating the diet of hens, even those stuck in cages, the omega-3 content of eggs can be increased. Is this healthier?
The limit on dietary cholesterol of 300 mg imposed by the AHA and the USDA in their guidelines, unnecessarily has my patients worrying about cholesterol in all the things that they eat. For example, there is a lot of cholesterol in shellfish. There is no evidence that eating shellfish is bad for the heart or your cholesterol profile. For example, this recent study showed no effect of eating cold water prawns on plasma cholesterol or lipoproteins.
The Bottom Line:
Eggs are an affordable (15 cents/egg) source of high quality protein and fat. Although they contain a lot of cholesterol, there is no evidence (with the possible exception of diabetics) that egg consumption is related to risk of coronary heart disease; they may in fact reduce the risk of stroke.
Since this new evidence has emerged, I regularly enjoy the deliciousness of a three egg omelet with cheese and other ingredients without guilt and I encourage my patients to do the same. Personally, especially in my home kitchen, I try to eat eggs that come from hens that are raised under more natural and humane circumstances as I view them as healthier than eggs from factory farms.
Not everyone is an egg lover and I’m fine with that. There is no evidence that you have to eat them. You could feel towards them as did Alfred Hitchcock :
“I’m frightened of eggs, worse than frightened, they revolt me. That white round thing without any holes … have you ever seen anything more revolting than an egg yolk breaking and spilling its yellow liquid? Blood is jolly, red. But egg yolk is yellow, revolting. I’ve never tasted it.”
In recent years, a steady stream of experts, including the ubiquitous Dr. Oz, have advised every one to take fish oil supplements to protect their heart health
In fact, there is little to no evidence that fish oil supplements or fish oil enhanced foods should be consumed for any health purpose.
Omega-3 fatty acids (also known as ω−3 or n−3) are polyunsaturated fatty acids (PUFA) that can be derived from marine or plant oils. They are considered essential fatty acids in humans, vital for normal metabolism but not synthesized by the human body.
The long chain omega-3 fatty acids eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) are felt to be the most beneficial. The best food source of DHA and EPA is cold water fatty fish and shellfish. The fish highest in these fatty acids are salmon, sardines, mackerel, herring and tuna.
Alpha-linolenic acid (ALA) is an omega-3 fatty acid which is predominantly found in plant oils (flaxseed, canola, and soybean oils) and walnuts. It can, to a limited extent, be converted in human bodies to EPA and DHA, thus can be considered a precursor.
There is some evidence that consuming fish on a regular basis is associated with lower risk of coronary heart disease and stroke. Therefore, I can agree with current AHA and USDA guidelines which recommend consumption of fatty fish at least twice a week and I advise this for my patients.
Predominantly on the basis of one very positive study performed in Italy in 1999 (the GISSI study, which gave EPA/DHA to heart attack survivors), most cardiologists, the AHA, and the supplement industry had concluded by 2005 that fish oil reduced mortality and cardiac morbidity. The best evidence then was that the fish oil supplement was helpful after a heart attack (so-called secondary prevention). However, there was a very powerful urge to extrapolate this recommendation to patients without heart disease (so-called primary prevention).
Such expanded recommendations were reflected in the media. For example, Forbes proclaimed
“One Supplement That Works:
A lot of nutritional supplements are quack medicines. Not fish oil”
By 2009 sales of OTC fish oil supplements had risen 18% in one year to 739 million and Americans were buying 1.8 billion worth of foods (such as margarine and peanut butter) fortified with extra omega-3s. By 2011, Americans were spending 1.1 billion on supplements.
GlaxoSmithKline developed and patented a high-concentration fish oil (Lovaza) that gained an indication for treating high triglycerides which had global sales of 1 billion dollars in 2008. Supported by heavy advertising and promotion to physicians (through dinner lectures, lunches and other promotions), this expensive version of fish oil is widely prescribed by physicians for reasons other than the very high triglyceride elevations it has an indication for.
“In the history of nutritional supplements there’s something striking about omega-3: the fact that it works. Much of the $25 billion a year that Americans spend on supplements is money down the drain”
While the second part of that sentence is true (the vast majority of supplements/nutraceuticals/minerals that Americans take in a search for longevity or arthritis relief are worthless) the first part is not true.
The subsequent hype for the benefits of fish oil supplements, especially in the world of nutritional supplement has been outrageous and inaccurate.
A typical product description reads as follows.
“We believe this is the highest quality Omega-3 available.
This highly concentrated Pharmaceutical Grade Omega-3 Fish Oil delivers 800mg of EPA and 600mg of DHA.
The important benefits of Omega-3 have been proven in thousands of independent studies by universities, governments, and health organizations. Because of such research, people around the world are now taking fish oil for reasons ranging from brain development, mild depression and heart function to arthritis and our immune systems.
It causes NO fishy or un-pleasant after taste.
This Omega 3 has been verified by a 3rd party to be Mercury Free.”
If one reads further down the page, however, the most important sentence is the following (and this is true for all supplements_
These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent any disease
So , the fish oil pushers make a series of totally unsubstantiated claims about the benefits followed by the statement that it is not intended to benefit any one in any way.
“overall, omega-3 PUFA supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and abolute measures of association”
Studies performed in the last 5 years of omega-3 PUFA supplementation do not support a role for them in reducing heart disease, either in high risk individuals without documented heart disease or those who have already had heart attacks.
Most of my patients continue to take fish oil supplements because they think that there may be a benefit without any down side. However, there are a number of potential down sides that should be considered.
1. There is no government regulation or measurement of the contaminants in fish oil supplements.
According to Consumer Reports
“Most tested pills are claimed to be “purified” or “free” of PCBs, mercury, or other contaminants, claims that have no specific regulatory definition, the Food and Drug Administration says. The agency has taken no enforcement action against any omega-3 maker over PCBs or other contaminants, an FDA spokeswoman said, because it has seen no public-health risk”
2. A major source of the fish oil in fish oil supplements, menhaden, is being over fished. Menhaden are a sardine-like forage fish that range in huge schools from Canada to Florida and into the Gulf. As filter feeders, they form an important base of the marine food chain. They have historically been harvested for food and later, for use as fertilizer and more recently for use in aquaculture and in omega-3 supplements. This fish, which has been called “the most important fish in the sea,” feeds on phytoplankton and is essential for a healthy marine ecosystem. The Atlantic States Marine Fisheries Commission (ASMFC) recently approved a 20% decrease in fish catch for the Atlantic Coast menhaden bait and reduction fisheries, The numbers of these fish have declined by 90% in the last 4 decades. Without doing extensive research on your particular fish oil supplement you can’t be sure you aren’t contributing to this problem.
So, the bottom line on fish oil supplements is that the most recent scientific evidence does not support any role for them in preventing heart attack, stroke, or death. There are potential down sides to taking them, including contaminants and the impact on the marine ecosystem. I don’t take them and I advise my patients to avoid them (unless they have triglyceride levels over 500.)
Americans want a “magic-bullet” type pill to take to ward off aging and the diseases associated with it. There isn’t one. Instead of buying pills and foods manipulated and processed by the food industry which promise better health, I advise following Michael Pollan’s simple advice
Many of my patients take a multivitamin supplement and a lot take individual vitamins or supplements. When they ask me if I think they are worthwhile I invariably say no, not from a cardiovascular standpoint. If they ask me if they should take the vitamin/supplement I usually respond that there is no evidence of harm and they should take it if some other reputable (not a chiropractor or naturopath) physician has advised it for a particular reason.
Data from the Center for Disease Control has shown that use of dietary supplements has increased progressively over the last decade . The graph below shows that despite evidence of no benefit , about a third of Americans continue to take a multivitamin/multimineral (defined as having 3 or more components)
It bears emphasizing-there is no evidence any multivitamin or vitamin improves your heart health or lowers your risk of heart disease or stroke!
This has been proven over and over again in multiple trials in which a vitamin with proposed healthy antioxidant properties (say Vitamine E or C) or anti-inflammatory properties (say homocysteine) has gone up against placebo. The vitamin is no better than placebo.
Apparently, the message that these chemicals are beneficial from the vitamin/nutraceutical/supplement industry is so persuasive and pervasive that my patients will continue to pay for and take their chosen vitamin or multivitamin despite my advice. The patients most likely to persist in taking the useless pills have a suspicion of doctors, the pharmaceutical industry and are convinced that “natural” methods (totally unproven by any scientific techniques) are superior to medically approved methods for disease prevention.
Nail In The Coffin for Multivitamins
The latest nail in the coffin for vitamins in the prevention of cardiovascular disease was published by Sesso et al in JAMA late last year .
This study reported data from the large, long term Physicians’ Health Study II which was started in 1997 and ended in 2011. Over 14 thousand male physicians over the age of fifty were entered into the study. On a random basis half of them took a multivitamin and half took a placebo (thus the study was randomized and placebo-controlled). Neither the patients nor their doctors knew who was taking what (thus double blind).
The study investigators measured who had what is termed in cardiology research a major adverse cardiovascular event, known as MACE. A MACE would in this case would be a stroke, a heart attack or death from cardiovascular disease.
The results of this really well done, large, controlled trial show absolutely no benefit of multivitamins in reducing any cardiovascular outcome. Those taking multivitamins were just as likely as those taking a placebo to have heart attacks, strokes or to die from any cause.
In the interest of full disclosure an earlier publication from this same study also in JAMA showed a very slight , barely significant lowering of risk of cancer by multivitamin use. However, the significance of these findings, given multiple other negative studies , lack of any mortality benefit, and any specific cancer effect has been widely questioned. An accompanying editorial , I think, best summarizes the weakness of the study and the authors, very clearly do not recommend multivitamin usage for preventing cancer.
In my previous post, I referenced USDA guidelines which recommend consuming dairy but only in a low-fat form. How did the mainstream nutritional community decide the American public should shift from full fat dairy to low or no fat dairy? Prior to the 1950s there was little concern in nutritional research about fat in the American diet. Beginning in the 1950s, it became apparent that heart disease, coronary artery disease (the cause of heart attacks) in particular, had become the major cause of mortality in western countries.
The American epidemiologist, Ancel Keys, became convinced in the mid 1950s that dietary fat and cholesterol were related to heart disease. In 1970 published his “Seven Countries Study” which found a correlation between per capita fat consumption and the prevalence of heart disease in seven cherry-picked countries. These kinds of studies can be useful for developing theories about which factors might cause disease, however, they cannot prove that a dietary factor causes the disease.
Messerli recently published a tongue-in-cheek analysis of the relationship between per capita chocolate consumption in a particular country and the number of Nobel Laureates produced by that same country that illuminates the weakness of this type of study.
This is the main figure from that study: Chocolate Consumption and Nobel Laureates
There is a very nice relationship demonstrated which suggests that the more chocolate consumed in a particular country, the more Nobel Laureates produced. However, no one would seriously believe that chocolate consumption causes the kind of brilliance needed to do achieve a Nobel prize. Clearly, there are confounding variables or factors. Sometimes, confounding factors are clear and can be accounted for, but often they are not clear and cannot be accounted for.
Early studies of this type demonstrated that there was a relatively strong association between the per capital supply of milk or some component of milk and heart disease mortality. In other studies, changes in gross milk production over time and changes in heart disease deaths were shown to correlate.
“the National institute of Health (NIH) had begun (by 1988) advising every American old enough to walk to restrict fat intake, and the president of the American Heart Association (AHA) had told Time magazine that if everyone went along, “we will have (atherosclerosis) conquered” by the year 2000. The Surgeon General’s Office itself had just published its 700-page landmark “Report on Nutrition and Health,” declaring fat the single most unwholesome component of the American diet.”
Such recommendations have resulted in a whole industry devoted to developing low-fat food-like substances which the public has perceived as healthier than the natural high fat original foods. Arguably, adoption of highly processed low-fat foods, which usually increase palatability by adding refined carbohydrates , sugar, or high-fructose corn syrup have contributed to America’s obesity epidemic. This, in turn through increasing obesity-associated diabetes, hypertension, and abnormal lipid profiles could have the unintended consequence of increasing heart disease.
The major focus of low-fat dietary recommendations has been to lower red meat consumption due to the high levels of saturated fat found in pork and beef. However, despite having a significantly different saturated fat composition, dairy products have been tarred with the same brush, so to speak. This has progressed to the point where, if one enters a frozen yogurt establishment (these businesses have proliferated at an alarming rate in the last few years) it is virtually impossible to find a full fat formulation of yogurt. Prominently featured are the words “no-fat” or “low-fat” with the implication that this is healthy for you. Instead of the natural fat of dairy , you have now been convinced to eat a form of dairy that has been highly processed, depleted of most nutrients and full of sugar and unrefined carbohydrates. To make up for the fat calories which might have left you more satiated without sharp peaks in blood glucose, you can substitute a whole panoply of sugary materials, chocolate, candies, or fruit.
It turns out that when the best epidemiological studies are examined in this area, the evidence suggests a protective effect of dairy on heart disease risk. Dr. Peter Elwood, a highly respected epidemiologist at the University of Wales, has consistently pointed this out based on his and other researchers’ studies.
To quote Elwood, the best epidemiological studies are “prospective cohort studies, based on data for individual subjects within a single community, with detailed attention given to confounding” variables. Such studies “give a much better basis for the examination of independent associations between food items and disease incidence than studies based on either ecological data or relationships with risk factors.”
In 2004, Elwood published a review of such studies which was published in the European Journal of Clinical nutrition. He found 10 studies worthy of inclusion. All but one study suggested that milk protects against heart disease. Those subjects consuming the most milk were less likely to have a heart attack or stroke than those consuming no milk. The relative risk for high volume milk drinkers versus those drinking no milk for “ischaemic heart disease” (this refers to coronary artery disease , the major cause of heart attacks) was 0.87. In other words, if you drank a lot of milk you were 13% less likely to have heart disease than if you drank none.
Elwood’s original research on this was called the Caerphilly Prospective Study. Between 1979 and 1983, 2500 men completed a food frequency questionnaire. During the following 21 years, the relative risk in men who drank more than a pint of milk per day, compared with the risk in men who drank no milk was 0.66 for ischemic heart disease and 0.84 for ischaemic stroke. In other words, high milk drinkers were 34% less likely to develop coronary heart disease, the major cause heart attacks.
All the studies reviewed were set up at times when reduced-fat milk was unavailable or scarce therefore the conclusion from the best available evidence in 2004 should have been that full fat dairy lowers your risk of heart attack and stroke.
For both the general public and for my cardiac patients I, therefore, differ strongly in my advice regarding dairy consumption from most published dietary guidelines. Keeping in mind that “all things in moderation” applies just as much in this area as any other, I advise full fat dairy consumption. This means that they can consume butter, milk, full-fat cheese and yogurt. I strongly advise utilizing dairy that comes from grass-fed , pasture-raised cows for reasons I will examine in subsequent posts. Each of these dairy products has a different fatty acid profile and therefore, likely a different effect on cholesterol profiles. Butter, in particular, may warrant separating out from the other dairy products because it is a very highly concentrated fat. However, since reviewing the published data on butter consumption and cardiovascular disease, I have personally gone back to fairly liberally applying butter (again, hopefully from grass-fed, pasture-raised cows) to a lot of my foods because there are few data suggesting that butter raises my risk of cardiovascular disease and the stuff tastes awesome.
Dietary guidelines recommend the consumption of milk and dairy products as an important part of a healthy, well-balanced diet The 2010 USDA Guidelines state:
“Milk and milk products contribute many nutrients, such as calcium, vitamin D (for products fortified with vita- min D), and potassium, to the diet. Moderate evidence shows that intake of milk and milk products is linked to improved bone health, especially in children and adolescents. Moderate evidence also indicates that intake of milk and milk products is associated with a reduced risk of cardiovascular disease and type 2 diabetes and with lower blood pressure in adults.”
However, dairy fat has been portrayed as the unhealthy component of milk and dairy products, largely because it is energy dense and a rich source of saturated fatty acids . Therefore, typical dietary advice recommends fat-reduced milk and dairy products.
Shockingly, and despite expert and government-backed recommendations, the advice to change to fat-reduced or skim milk and dairy products is not supported by any prospective scientific studies.
The main reason cited for the recommendations is that the consumption of saturated fatty acids is related to an increase in total cholesterol which in turn has been related to increased coronary heart disease-the major cause of heart attacks. As we discuss this topic more, we will discover that this logic is flawed because 1) saturated fats are a diverse family of compounds with varying effects on the cholesterol profile and 2) the cholesterol profile itself is incredibly complex and simple measurements of “bad” (HDL) and “good” (LDL) cholesterol alone probably don’t tell us enough about the risk of heart disease .
Partially as a result of these guidelines, the pattern of dairy fat intake has changed considerably in the last 40 years, a time frame during which the modern obesity epidemic has developed in the United States Butter consumption has dropped considerably and low fat milk has supplanted full fat milk as the preferred product. In parallel, dairy fat consumption from other, possibly less healthy sources such as prepared foods, pizza, industrially produced margarine.
When epidemiologists have scientifically reviewed the relationship between high fat dairy consumption and heart disease or obesity, almost invariably they have found an inverse relationship. That is, the more dairy consumed, the lower the risk of heart disease and the less obesity.
In subsequent posts we’ll look in more detail at the evidence supporting dairy consumption in reducing heart disease and obesity.